The Triple Aim framework came about in 2007. The goal –  improve the health of a population, enhance the patient experience, and reduce per capita health care costs. The Triple Aim was meant to optimize health system performance. The one area the Triple Aim neglects is the satisfaction of physicians and clinical staff. And to this, the Quadruple Aim was created. This built on the Triple Aim, but added the improvement of work life for clinicians, as burnout was (and is) high.

Burnout and Medical Errors

Systems with higher rates of burnout tend to experience increased medical errors, lack of productivity and reduction in work hours, all of which impede the delivery of quality care to patients. Physician burnout, has been found to double the likelihood of patient safety incidents. In order to combat this problem in end-of-life care, we have to understand the root cause. Burnout can be triggered by low patient satisfaction, reduced health outcomes or increased costs. While dissatisfaction among providers is relatively common, it’s especially burdensome for hospice and palliative care providers. Frail patients are extremely susceptible to error given their already declining health status, and these providers are more inclined to experience hardships associated with burnout, such as:

  • Lack of self-confidence in communication skills with patients and families
  • Time pressures that hinder effective communication
  • Communicating bad news
  • Discussing pain, suffering, and death with patients

Education, Training, and Resources

Providing physicians the education, training, and resources to have this conversation helps increase physician competence and confidence. Providing physicians primary palliative care education and training helps them feel more comfortable having advance care planning conversations. Formal end-of-life training is making its way into the medical school curriculum. All four Massachusetts medical schools have come together to improve palliative care training. Oregon Health & Science University requires their medical students to pass a test on end-of-life conversations.

Although training and education helps, some physicians will still feel uncomfortable having these conversations. Embedding palliative care clinicians into high-risk settings has become recently popular, and proven helpful for both patients and other providers within the care team. An embedded palliative care clinician model was tested at three Midwestern academic medical centers. Over a six month period, non-palliative care clinicians at all sites reported an increased level of comfort and skills in conducting goals-of-care conversations.

Although physician burnout continues to be an issue across the US, there are efforts being put into place to help. End-of-life conversations are difficult for many physicians, but resources and palliative care services can help alleviate the stress around these crucial conversations. Supporting physicians will result in a better patient experience, and hopefully a better experience for physicians.

National Doctors’ Day is celebrated on March 30th. We honor all doctors on this day, especially those committed to impacting end-of-life care.

About the Author


Vynca, based in Palo Alto, Calif., provides comprehensive advance care planning technology solutions that enable health care organizations to deliver high-quality end-of-life care consistent with an individual’s preferences.

The company helps patients, families and health care providers have meaningful conversations about future care preferences, ensure that wishes are documented accurately and provides real-time access to this critical information throughout the care continuum.