By David W. Baker, MD, MPH, FACP, Executive Vice President for Health Care Quality Evaluation, The Joint Commission, and Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety
“What are the largest sources of extraneous cognitive load – the amount of information a person holds and processes within his/her working memory – where you work?” This question was posed to physicians attending a recent webinar as part of the American Medical Association’s (AMA) Steps Forward™ series.
Several physicians offered frequent sources of their cognitive load, including:
- electronic health records
- economic demands
- staff needs
- constant interruptions
To help physicians learn how to manage their extraneous cognitive load, Elizabeth Harry, MD, discussed her study from The Joint Commission Journal on Quality and Patient Safety (JQPS), “Physician Task Load and the Risk of Burnout Among U.S. Physicians in a National Survey.” The study evaluated whether task load correlated with burnout scores in a large national survey of U.S. physicians between October 2017 and March 2018.
Short-Term Working Memory
During the webinar, Dr. Harry explained that all humans have a short-term working memory that controls all learning and decision making. Just as a cup can get overfilled, so can our short-term working memory. Physiologic and emotional stress can cause this overfill, as can the extent of these three types of loads:
- Intrinsic Load: How complex is the task itself?
- Extraneous Load: How much working memory is needed to store the critical pieces of information to complete the task? How distracted are you?
- Germane Load: How much working memory do you have to spend learning the information to complete the task?
When we overload our working memory, load shedding may occur. “Load shedding is when you start losing pieces of data and you are completely unaware that you lost it – putting us at risk for medical errors,” cautioned Dr. Harry.
Physician Task Load and Burnout
The JQPS study set out to determine if there is a relationship between physician task load (PTL) and burnout – and, if so, how strong it is.
Cognitive load or task load was measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX). The NASA-TLX was chosen to evaluate PTL due to its robust validation and use across many industries over the past 30 years. Four domains/subscales were used from the NASA-TLX to measure:
- mental demand
- physical demand
- temporal demand
- perceived effort required
Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either scale was considered a manifestation of professional burnout.
More than 5,400 physicians responded to the survey. A significant association was found between PTL and burnout. For every 40-point (10%) decrease in PTL, there was 33% lower odds of experiencing burnout – providing a framework to approach the practice environment and reduce burnout.
Reducing Physician Task Load?
Dr. Harry believes three factors can help reduce PTL:
- increasing standardization across units in hospitals, processes, and teams and providers
- decreasing redundancy in the communication of data, ways to receive the same type of data and task delegation
- consolidating data and reducing split attention by bringing data and materials together for workflows, process coupling, and team consensus on what warrants interruptions and blocks of interrupted work
Furthermore, Dr. Harry encourages leaders to support change by acknowledging that cognitive overload and burnout is not safe for staff and patients.
To learn more about the study, please visit the JQPS website.
David Baker, MD, is the Executive Vice President for Health Care Quality Evaluation at The Joint Commission. In this role, he leads the Department of Standards and Survey Methods, the Department of Quality Measurement, and the Department of Research. He oversees the development of performance measures, standards, survey methods, and National Patient Safety Goals for all Joint Commission accreditation and certification programs. He is also Editor-in-Chief for The Joint Commission Journal on Quality and Patient Safety.