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Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review

Open AccessPublished:September 26, 2019DOI:https://doi.org/10.1016/j.mayocpiqo.2019.07.006

      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 workflow changes such as process improvement initiatives or policy changes within the organization. Technology 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.

      Abbreviations and Acronyms:

      EHR (electronic health record), MBI (Maslach Burnout Inventory), WTR (Working Time Regulations)
      Article Highlights
      • There 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 systems. Many causes of burnout derive from organizational- and system-level factors, including electronic health records (EHRs).
      • Most studies evaluating the impact of organization-directed interventions 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.
      • There is evidence from a few high-quality studies that (1) the largest benefits result from interventions that improve workplace processes, promote team-based care, and incorporate the use of scribes or medical assistants to complete EHR documentation 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.
      • Evidence 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.
      The prevalence of physician burnout is substantial, with more than half of US physicians reporting at least one symptom of burnout, which is significantly higher than that in the general population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      Burnout is defined as a long-term stress reaction marked by loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a lack of sense of personal accomplishment.
      • Maslach C.
      • Schaufeli W.B.
      • Leiter M.P.
      Job burnout.
      Causes of physician burnout include time pressure, chaotic environments, requirements for electronic health records (EHRs), and responsibilities outside of work.
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.
      Physician burnout can affect physician health and quality of care.
      Agency for Healthcare Research and Quality
      Physician Burnout.
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      • Sinsky C.A.
      • Dyrbye L.N.
      • West C.P.
      • Satele D.
      • Tutty M.
      • Shanafelt T.D.
      Professional satisfaction and the career plans of US physicians.
      As a result of stress, physicians may experience depression or anxiety, may engage in alcohol and/or drug abuse,
      • Montgomery A.J.
      • Bradley C.
      • Rochfort A.
      • Panagopoulou E.
      A review of self-medication in physicians and medical students.
      and have suicide rates that are 1.2 to 2.4 times higher than that of the general population.
      • Schernhammer E.S.
      • Colditz G.A.
      Suicide rates among physicians: a quantitative and gender assessment (meta-analysis).
      Work-related stress can also lead to lower patient satisfaction and care quality and increased medical error rates and malpractice risk.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      • Balch C.M.
      • Oreskovich M.R.
      • Dyrbye L.N.
      • et al.
      Personal consequences of malpractice lawsuits on American surgeons.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • et al.
      Burnout and medical errors among American surgeons.
      Burnout also has potentially serious financial implications for the health care system
      • 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.
      • Landon B.E.
      • Reschovsky J.D.
      • Pham H.H.
      • Blumenthal D.
      Leaving medicine: the consequences of physician dissatisfaction.
      • Sibbald B.
      • Bojke C.
      • Gravelle H.
      National survey of job satisfaction and retirement intentions among general practitioners in England.
      by leading to physician shortages and in costs to replace a physician, which can exceed $500,000 to $1,000,000 per physician.
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      • Buchbinder S.B.
      • Wilson M.
      • Melick C.F.
      • Powe N.R.
      Estimates of costs of primary care physician turnover.
      Interventions to address burnout have been classified as either physician-directed or organization-directed.
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      Physician-directed interventions 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 competency. However, these supportive physician-directed approaches may be insufficient because they address individual solutions. Burnout more often stems from organizational- or system-level factors,
      • Friedberg M.W.
      • Chen P.G.
      • Van Busum K.R.
      • et al.
      Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy.
      and interventions to prevent burnout may be more effective when they focus on changing the system rather than individual physicians.
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      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 effect of organization-directed workplace interventions 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 reported on organization-directed interventions for physician burnout related to work, the workplace, or workflow. Search terms included physician, 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 literature 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 independent 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 structured 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
      Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009). Centre for Evidence-Based Medicine website.
      (Table 1) by 2 independent reviewers (K.J.T.C. and A.A.), and disagreements were resolved by a third reviewer (T.B.).
      Table 1Study Characteristics Stratified by Intervention Type
      ACGME = Accreditation Council for Graduate Medical Education; ACP/ASIM = American College of Physicians/American Society of Internal Medicine; her = electronic health record; ESS = Epworth Sleepiness Scale; JSS = Physician Job Satisfaction Scale; ICU = intensive care unit; IT = information technology; MBI = Maslach Burnout Inventory; MEMO = Minimizing Error, Maximizing Outcome; NA = not available; NR = not reported; NYC = New York City; OWL = Office and Work Life measures; PWS = Physician Worklife Study; RCT = randomized controlled trial; STAI = State-Trait Anxiety Inventory; WTR = Working Time Regulations.
      Reference, yearCountryStudy designNo. of participantsPopulation and settingType of interventionOutcomeFollow-upLevel of evidence
      Oxford Centre for Evidence-based Medicine Levels of evidence18: 1b = individual RCT (with narrow confidence interval); 2b = individual cohort study (including low-quality RCT; eg, <80% follow-up); 4 = case series (and poor-quality cohort and case control studies).
      Teamwork (N=20)
       Chapman & Blash,
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      2017
      United StatesCross-sectional886Primary care practicesTeamwork: 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 rolesStaff satisfaction4 y4
       Contratto et al,
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      2016
      United StatesPre-post intervention survey9Physicians

      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 information14-Item survey4 mo4
       Contratto et al,
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      2017
      United StatesQuasi-experimental (single-group pre-post intervention) mixed-methods7Academic general internal medicine practiceTeamwork: Clerical support personnel for physician order entryPhysician satisfaction4 mo4
       Danila et al,
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      2018
      United StatesPre-post intervention survey6Physicians (3 rheumatologists and 3 endocrinologists)

      Rheumatology and endocrinology clinics
      Teamwork: Use of scribesJSS6 wk4
       Gidwani et al,
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      2017
      United StatesRCT4Physicians

      Academic family medicine clinic
      Teamwork: Use of scribes to draft all relevant documentationPhysician satisfaction, measured by a 5-item instrument that included physicians’ perceptions of medical record quality and accuracy1 y1b
       Heaton et al,
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      2016
      MultinationalSystematic reviewNANATeamwork: Use of scribesPhysician satisfactionNA4
       Hung et al,
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      2018
      United StatesPre-post intervention survey680Physicians

      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 membersMBI3 y4
       Imdieke & Martel,
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      2017
      United StatesQuasi-experimental, nonrandomized pre- and post-intervention study2Internal medicine physicians

      Hospital-based, outpatient primary care clinic
      Teamwork: Incorporating medical scribes in an ambulatory clinic to support physician documentation in the electronic medical recordPhysician satisfaction4-6 wk4
       Koshy et al,
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      2010
      United StatesNonrandomized, static-group comparison study5Urologists, residents

      Urology clinic within a single academic medical center
      Teamwork: Scribes to record electronic medical information throughout the patient-physician encounterPhysician acceptance and satisfaction10 mo4
       Linzer et al,
      • 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.
      2015
      United StatesCluster RCT166 (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 projectsSurvey tools from MEMO and PWS12 mo, 18 mo2b
       Linzer et al,
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      2017
      United StatesCluster RCT165Primary 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 managementOWL6 mo, 12 mo2b
       McCormick et al,
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      2018
      United StatesPre-post intervention survey6Urologists

      Academic urology clinic
      Teamwork: Use of scribesWork satisfaction3 mo4
       Pierce et al,
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      2017
      United StatesPre-post intervention survey55Physicians 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 redesignNR3 y4
       Pozdnyakova et al,
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      2018
      United StatesProspective, pre-post pilot study6General internal medicine facultyTeamwork: Use of scribes to complete EHRWorkplace satisfaction; burnout1 wk4
       Quenot et al,
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      2012
      FranceLongitudinal, monocentric, before-and-after, interventional study4Physicians

      ICU
      Teamwork: Intensive communication strategy regarding end-of-life practices in the ICU to alleviate stress for caregiversMBIPost-intervention4
       Shaw et al,
      • Shaw J.G.
      • 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.
      2017
      United StatesPre-post intervention surveyNRMedical doctors

      NR
      Teamwork: Team-based primary care redesign, “Primary Care 2.0”, with the goal of addressing 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)NR5 mo4
       Shultz & Holmstrom,
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      2015
      MultinationalSystematic reviewNAEmergency department, urology, or cardiology cliniciansTeamwork: Use of scribesClinician satisfactionNA4
       Was & Cornaby,
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      2016
      United StatesPre-post intervention survey23Residents

      Large academic center
      Teamwork: Common space for residents (ie, “Gas Lounge”)NRPost-intervention4
       West et al,
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      2014
      United StatesRCT74Physicians

      Department of medicine at the Mayo Clinic
      Teamwork: 19 Biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small group learningJSS, Empowerment at Work Scale, Medical Outcomes Study Short-Form Health Survey, MBI, Perceived Stress Scale, Jefferson Scale of Physician Empathy1 y1b
       Willard-Grace et al,
      • 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.
      2017
      United StatesCross-sectional236Clinicians

      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 definedMBINR4
      Time (N=14)
       Ali et al,
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      2011
      United StatesCluster RCT45Physicians with various specialties

      ICU
      Time: Two intensivist staffing schedules were compared: continuous and interrupted (rotations every 2 wk) for 14 moScales derived from the National Study of the Changing Workforce9 mo1b
       Desai et al,
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      2018
      United StatesCluster-randomized trial80First-year residents

      63 Internal medicine residency practices
      Time: Duty hour policies of the 2011 ACGMEOverall well-being, MBI7 mo1b
       Fassiotto & Maldonado,
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      2016
      United StatesPre-post intervention survey60Medical school faculty

      NR
      Time: Time-banking intervention measures unacknowledged teaching, service, and clinical activities and acknowledges them with practical rewardsNRPost-intervention4
       Garland et al,
      • 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.
      2012
      CanadaCrossover RCT34Physicians

      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 shiftsMBI (emotional exhaustion subscale)Post-intervention1b
       Kim & Wiedermann,
      • 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 later [abstract].
      2011
      United StatesProspective cohort56Residents

      Large pediatric training program
      Time: 2003 ACGME work hour limitsNR7 y4
       Landrigan et al,
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      2008
      United StatesProspective cohort220Residents

      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 wkMBI1 y4
       Lucas et al,
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      2012
      United StatesCluster randomized crossover noninferiority trial62Physicians

      University-affiliated teaching hospital
      Time: Assignment to random sequences of 2- and 4-wk rotationsQuestionnaire includes questions from MEMO study, Perceived Stress Scale, MBI, national job burnout survey2/4 wk1b
       Moeller & Walker,
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      2017
      United StatesPre-post intervention surveyNRPhysicians

      NR
      Time: Practice Refresh pilot 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-careNRNR4
       Morrow et al,
      • 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.
      2014
      United KingdomCross-sectional82Junior 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 periodsNANA4
       Parshuram et al,
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      2015
      CanadaRCT47Residents

      University-affiliated ICUs
      Time: In-house overnight schedules of 24, 16, or 12 hMBI2 mo2b
       Ripp et al,
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      2015
      United StatesPre-post intervention survey128 (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 hMBI, ESS1 y4
       Schuh et al,
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      2011
      United StatesProspective, unblinded study34Neurology 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 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 averagingMBI1 mo4
       Shea et al,
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      2014
      United StatesRCT106Graduate 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 wkMBIPost-intervention1b
       Tucker et al,
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      2010
      WalesCross-sectional336Residents and interns

      NR
      Time: Schedule designQuestionnaire developed for studyNA4
      Transitions (N=9)
       Albadry et al,
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      2014
      EgyptCross-sectional140Residents and assistant lecturers

      Outpatient clinic
      Transitions: Six Sigma methodology as quality improvement interventionMBI6 mo4
       Amis & Osicki,
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      2018
      United KingdomPre-post intervention survey13First-year residentsTransitions: A checklist aimed to reduce the number of inappropriate prescribing tasksJob satisfaction3 Weekends4
       Callahan et al,
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      2018
      United StatesPre-post intervention survey9Fellows

      NR
      Transitions: Bundle of evidence-based interventions to improve burnout and professional satisfaction that were designed to fit the fellowship programESS, quality of life6 mo4
       Dunn et al,
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      2007
      United StatesNoncontrolled prospective intervention study22-32Physicians

      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 instrumentsACP/ASIM survey on physician satisfaction, MBI6 y4
       Giannini et al,
      • 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.
      2013
      ItalyPre-post intervention survey71Doctors

      ICU
      Transitions: Increase in daily visiting time to at least 8 h (policy change)MBI, STAI6 mo, 12 mo4
       Hung et al,
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      2018
      United StatesPre-post intervention survey680Physicians

      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 membersMBI3 y4
       Lee et al,
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      2017
      United StatesPre-post intervention surveyBaseline, 18; postin-tervention, 15Neuroradiology 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–image interpretive reading room workflows14-Question survey, Likert scale rating 1-51 mo4
       Linzer et al,
      • 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.
      2015
      United StatesCluster RCT166 (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 projectsSurvey tools from MEMO and PWS12 mo, 18 mo2b
       Linzer et al,
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      2017
      United StatesCluster RCT165Primary 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 managementOWL6 mo, 12 mo2b
      Technology (N=10)
       Agha et al,
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      2010
      United StatesNR9Pulmonary, rheumatology, and endocrine physicians

      NR
      Technology: To measure the impact of EHR use on physician satisfactionNRNR4
       Babbott et al,
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      2013
      United StatesProspective422Internal medicine and family medicine physiciansTechnology: 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 usedNRNR4
       Beam et al,
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      2017
      United StatesPre-post intervention survey158Physicians

      Neonatal ICU
      Technology: Computerized physician order entry implementationJob satisfaction1 y4
       Ehrlich et al,
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      2016
      United StatesPre-post intervention survey25Ophthalmologists

      Large academic ophthalmology department
      Technology: EHR system30-Question survey using Likert scale rating, job satisfaction24 mo4
       Heyworth et al,
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      2012
      United StatesPre-post intervention survey163Primary care and specialty

      NR
      Technology: To measure predictors of physician satisfaction following EHR adoptionMassachusetts eHealth Collaborative surveyPost-intervention4
       Joseph et al,
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      2017
      United StatesPre-post intervention surveyNRPhysicians

      NR
      Technology: The impact of a brief, intensive technology deployment and training intervention that was aimed at improving individual clinician’s efficiency in using EHRNRNR4
       Lapointe et al,
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      2018
      United StatesPre-post intervention survey25Internal medicine residents

      591-Bed urban hospital
      Technology: EHR-based text paging system to communicate with internal medicine residentsStress6 mo4
       Menachemi et al,
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      2009
      United StatesCross-sectional4203Primary care physicians and clinical specialists

      Outpatient settings
      Technology: To evaluate the relationship between physician IT adoption and practice satisfactionSurvey using Likert scale questions on job/practice satisfactionNA4
       Milenkiewicz,
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      2017
      United StatesPre-post intervention surveyNRPhysicians

      Department of Addiction Medicine at Kaiser

      Permanente
      Technology: To test the usability of an EHR tool to improve and standardize the documentation processNRPost-intervention4
       Wylie et al,
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      2014
      United StatesCross-sectional2365Primary care physicians

      Practice with more than 10 physicians
      Technology: To identify how EHR use affected clinical practiceLikert-type scale questions regarding how EHR affected medical practiceNA4
      a ACGME = Accreditation Council for Graduate Medical Education; ACP/ASIM = American College of Physicians/American Society of Internal Medicine; her = electronic health record; ESS = Epworth Sleepiness Scale; JSS = Physician Job Satisfaction Scale; ICU = intensive care unit; IT = information technology; MBI = Maslach Burnout Inventory; MEMO = Minimizing Error, Maximizing Outcome; NA = not available; NR = not reported; NYC = New York City; OWL = Office and Work Life measures; PWS = Physician Worklife Study; RCT = randomized controlled trial; STAI = State-Trait Anxiety Inventory; WTR = Working Time Regulations.
      b Oxford Centre for Evidence-based Medicine Levels of evidence
      Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009). Centre for Evidence-Based Medicine website.
      : 1b = individual RCT (with narrow confidence interval); 2b = individual cohort study (including low-quality RCT; eg, <80% follow-up); 4 = case series (and poor-quality cohort and case control studies).

      Results

      Literature searches yielded 633 unique citations (Figure 1), of which 140 articles were eligible for full-text screening. Following full-text screening, 50 citations were included in the study,
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shaw J.G.
      • 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.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • 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.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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.
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • 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.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      of which 36 (72.0%) were full-length articles
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • 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.
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • 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.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      and 14 (28.0%) were conference abstracts.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Shaw J.G.
      • 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.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • 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.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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 later [abstract].
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      Figure thumbnail gr1
      Figure 1PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      of literature search.

      Study and Physician Characteristics

      Table 1 presents the characteristics of the 50 included studies.
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shaw J.G.
      • 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.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • 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.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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.
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • 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.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      Most (40) studies were from the United States,
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Shaw J.G.
      • 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.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • 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.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      followed by Europe (5),
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • 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.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • 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.
      Canada (2),
      • 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.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      Egypt (1),
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      and multinational (2).
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      Study designs included randomized controlled trials (10),
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • 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.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      pre-post intervention surveys (24),
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shaw J.G.
      • 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.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      prospective studies (5),
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      cross-sectional studies (7),
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • 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.
      • 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.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      and other designs (4).
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      The included studies evaluated interventions among primary care physicians and residents (12),
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • 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.
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      inpatient and outpatient secondary care physicians (eg, intensive care, surgery) (15),
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      • 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.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      residents (eg, intensive care, internal medicine, neuroradiology, pediatric) (13),
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • 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.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      a mixture of primary and secondary care physicians (3),
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      and groups of physicians with specialty unspecified (7).
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Shaw J.G.
      • 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.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.

      Measures of Burnout

      The most frequently used measure of burnout (15 studies) was the Maslach Burnout Inventory (MBI), a validated measure considered the criterion standard for identifying burnout.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • 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.
      • Desai S.V.
      • Asch D.A.
      • Bellini L.M.
      • et al.
      iCOMPARE Research Group
      Education outcomes in a duty-hour flexibility trial in internal medicine.
      • 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.
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Lucas B.P.
      • Trick W.E.
      • Evans A.T.
      • et al.
      Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial.
      • Parshuram C.S.
      • Amaral A.C.
      • Ferguson N.D.
      • et al.
      Canadian Critical 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Shea J.A.
      • Bellini L.M.
      • Dinges D.F.
      • et al.
      Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • 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.
      Sixteen studies developed their own surveys to measure outcomes related to physician burnout including job satisfaction, burnout, depersonalization, fatigue, and stress.
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      Additional measures included the Physician Job Satisfaction Scale,
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      Epworth Sleepiness Scale,
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      Office and Work Life measures,
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      survey tools from the Minimizing Error, Maximizing Outcome study and the Physician Worklife Study,
      • 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.
      scales derived from the National Study of the Changing Workforce,
      • Ali N.A.
      • Wolf K.M.
      • Hammersley J.
      • et al.
      Midwest Critical Care Consortium
      Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.
      Massachusetts eHealth Collaborative survey,
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      and American College of Physicians/American Society for Internal Medicine physician satisfaction survey.
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      Two studies
      • Shaw J.G.
      • 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.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      provided qualitative findings, and 10 studies did not report the instrument used to measure burnout.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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 later [abstract].
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • 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.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.

      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 physicians. 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.
      Figure thumbnail gr2
      Figure 2Number of studies by intervention type. EHR = electronic health record.
      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 interventions that are included in the 50 studies we assessed). Thirty-five of the 50 workplace interventions (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.
      Figure thumbnail gr3
      Figure 3Proportion 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 = individual randomized controlled trial (with narrow confidence interval); 2b = individual cohort study (including low-quality randomized controlled trials; eg, less than 80% follow-up); 4 = case series (and poor-quality cohort and case-control studies).

      Study Quality

      The evaluation of study quality using the Oxford Centre for Evidence-based Medicine Levels of Evidence
      Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009). Centre for Evidence-Based Medicine website.
      is shown in Table 1. The majority 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.
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shaw J.G.
      • 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.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • 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.
      • Fassiotto M.A.
      • Maldonado Y.A.
      A time banking system to support workplace flexibility. Paper presented at: International Conference on Physician Health.
      • 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 later [abstract].
      • Landrigan C.P.
      • Fahrenkopf A.M.
      • Lewin D.
      • et al.
      Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
      • Moeller M.F.
      • Walker C.
      Practice refresh: A 1-month intervention to rebuild physician efficiency and wellness. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 27-28.
      • 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.
      • Ripp J.A.
      • Bellini L.
      • Fallar R.
      • Bazari H.
      • Katz J.T.
      • Korenstein D.
      The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study.
      • Schuh L.A.
      • Khan M.A.
      • Harle H.
      • et al.
      Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences.
      • Tucker P.
      • Brown M.
      • Dahlgren A.
      • et al.
      The impact of junior doctors' worktime arrangements on their fatigue and well-being.
      • Albadry A.A.
      • Sleem A.N.
      • Montasser N.A.
      • Naggar E.-S.A.E.
      Effect of quality improvement intervention on occupational burnout in Mansoura University Hospitals, Egypt. Paper presented at: WELL-Med Conference.
      • Amis S.M.
      • Osicki T.H.E.
      Can patient safety be improved by reducing the volume of "inappropriate prescribing tasks" handed over to out-of-hours junior doctors?.
      • Callahan S.
      • Enfield K.B.
      • Sturek J.
      • et al.
      An innovative, evidence-based, fellow-driven bundle to improve professional satisfaction and wellness [abstract].
      • Dunn P.M.
      • Arnetz B.B.
      • Christensen J.F.
      • Homer L.
      Meeting the imperative to improve physician well-being: assessment of an innovative program.
      • 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.
      • Lee M.H.
      • Schemmel A.J.
      • Pooler B.D.
      • et al.
      Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction.
      • Agha Z.
      • Roter D.
      • Laud P.
      • et al.
      Patient-centered communication and physicians use of electronic medical records.
      • Babbott S.
      • Manwell L.
      • Brown R.
      • et al.
      Electronic health records and physician stress in primary care: results from the MEMO Study.
      • Beam K.S.
      • Cardoso M.
      • Sweeney M.
      • Binney G.
      • Weingart S.N.
      Examining perceptions of computerized physician order entry in a neonatal intensive care unit.
      • Ehrlich J.R.
      • Michelotti M.
      • Blachley T.S.
      • et al.
      A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system.
      • Heyworth L.
      • Zhang F.
      • Jenter C.A.
      • et al.
      Physician satisfaction following electronic health record adoption in three Massachusetts communities.
      • Joseph C.
      • Ross E.
      • Tuyen L.
      Rebooting the joy of practice = clinical/operational leadership + workflow standardization + technology. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 29-30.
      • Lapointe R.
      • Bhesania S.
      • Tanner T.
      • Peruri A.
      • Mehta P.
      An innovative approach to improve communication and reduce physician stress and burnout in a university affiliated residency program.
      • Menachemi N.
      • Powers T.L.
      • Brooks R.G.
      The role of information technology usage in physician practice satisfaction.
      • Milenkiewicz R.V.
      The less clicks the better: improving the documentation workflow process for physicians. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 97-98.
      • Wylie M.C.
      • Baier R.R.
      • Gardner R.L.
      Perceptions of electronic health record implementation: a statewide survey of physicians in Rhode Island.
      High-quality studies were limited to Teamwork, Time, and Transitions 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 physicians.
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Danila M.I.
      • Melnick J.A.
      • Curtis J.R.
      • Menachemi N.
      • Saag K.G.
      Use of scribes for documentation assistance in rheumatology and endocrinology clinics: impact on clinic workflow and patient and physician satisfaction.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Hung D.Y.
      • Harrison M.I.
      • Truong Q.
      • Du X.
      Experiences of primary care physicians and staff following lean workflow redesign.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • 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.
      • Linzer M.
      • Poplau S.
      • Brown R.
      • et al.
      Do work condition interventions affect quality and errors in primary care? results from the Healthy Work Place Study.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Pierce R.G.
      • Anoff D.
      • Cumbler E.
      • et al.
      A team-based and organizational framework for fostering resilience and well-being in academic hospital medicine. Paper presented at: American Conference on Physician Health; October 12-13, 2017; San Francisco, CA. Abstract book, pp 1-2.
      • Pozdnyakova A.
      • Laiteerapong N.
      • Volerman A.
      • et al.
      Impact of medical scribes on physician and patient satisfaction in primary care.
      • Quenot J.P.
      • Rigaud J.P.
      • Prin S.
      • et al.
      Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
      • Shaw J.G.
      • 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.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      • Was A.
      • Cornaby T.
      The ideal gas lounge: boosting resident happiness with empowerment and common space improvements. Paper presented at: International Conference on Physician Health.
      • West C.P.
      • Dyrbye L.N.
      • Rabatin J.T.
      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • 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.
      All of these subcategories of teamwork generally improved burnout, satisfaction, and stress (Table 2). A cross-sectional survey associated greater perceived capabilities of the care team with lower prevalence of exhaustion and cynicism, a higher likelihood to recommend the clinic as a place to work, and greater feasibility of providing primary care.
      • 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.
      Expanding the duties of medical assistants to add EHR documentation, health coaching, or navigation and/or management of population health and between-visit care improved survey scores of professional fulfillment
      • Shaw J.G.
      • 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.
      and practice satisfaction.
      • Chapman S.A.
      • Blash L.K.
      New roles for medical assistants in innovative primary care practices.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician satisfaction.
      • McCormick B.J.
      • Deal A.
      • Borawski K.M.
      • et al.
      Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.
      • Shultz C.G.
      • Holmstrom H.L.
      The use of medical scribes in health care settings: a systematic review and future directions.
      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 efficiencies.
      • Contratto E.C.
      • Estrada C.
      • Romp K.G.
      • Agne A.
      • Willett L.L.
      The impact of physician order entry clerical support on physician satisfaction and productivity.
      • Contratto E.
      • Romp K.
      • Estrada C.A.
      • Agne A.
      • Willett L.L.
      Physician order entry clerical support improves physician satisfaction and productivity.
      • Gidwani R.
      • Nguyen C.
      • Kofoed A.
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Heaton H.A.
      • Castaneda-Guarderas A.
      • Trotter E.R.
      • Erwin P.J.
      • Bellolio M.F.
      Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis.
      • Imdieke B.H.
      • Martel M.L.
      Integration of medical scribes in the primary care setting: improving satisfaction.
      • Koshy S.
      • Feustel P.J.
      • Hong M.
      • Kogan B.A.
      Scribes in an ambulatory urology practice: patient and physician sat