Physicians Take On Burnout and Provide Solutions

Michigan Medicine - September/October 2016

By Allie McLary for Michigan State Medical Society

Health care professionals carry an inordinate amount of responsibility, working every day to provide the highest quality of care to their patients. Starting as early as medical school, future physicians, nurses and administrators work around the clock to learn and put their caregiving expertise into practice. This hard work, pressure and stress can lead to burnout for physicians and their staff.

Physicians are taking on the issue of burnout, voicing the importance of self care in an industry focused on helping others. By practicing healthy behaviors and coping mechanisms, physicians and their staff can more efficiently treat their patients and share those healthy habits.

They're speaking up about the symptoms and how to address burnout in a way that can stand the test of time and work for all generations of health care professionals.

Marwan Aboulijoud, MD, FACS, CPE, MMM
Director of Henry Ford Transplant Institute, Henry Ford Hospital

How does burnout come about?

I think the general issue of burnout typically begins when people start getting busy and sacrifice components in their lives that are important for them, such as self care, hobbies, etc. They lose the sense of reward and meaning.

Specifically, in health care, physicians are working in a competitive market where they're expected to always do good and keep up on the changes in health care. Many are working 60 to 70 hours a week while hearing what they need to do differently or better, instead of the great job they are currently doing. Things like sacrificing a social life, the perceptions of the world on health care providers and recovering from a hard day are pressures some physicians deal with well, but many don't.

Burnout isn't just limited to physicians, it's also present in nurses and other medical staff. Physicians shouldn't just be hired for a job, but for a life-long career where they can advance and grow.

What are the symptoms of physician burnout?

As a result of burnout, physicians fall on a scale of emotions starting with emotional exhaustion, moving to depersonalization and then finally losing their sense of personal accomplishment. These feelings create a disconnect between their care and their patients.

Most physicians feeling burnout fall in the emotional exhaustion category, the precursor to depression. They are physically there, but not present. Loss of glory, feeling drained and experiencing a lack of drive, initiative and purpose are all signs of emotional exhaustion.

In cases of depersonalization, physicians often refer to patients as a room number and describe a particular event in a very impersonal way. This detachment is often used as a coping mechanism in our profession, but a complete lack of empathy detracts from the care of the patient.

It's important for physicians to hold on to that sense of accomplishment, to feel like what they do is worth it. In an ever-changing world of treatments and technology, thank yous are few and far between. Maintaining that appreciation for what you do is an active exercise that needs to happen every day.

What behaviors can physician burnout lead to?

When physicians are dealing with emotional exhaustion and depersonalization, they put up an emotional wall between them and the patient. Some of that is necessary in the medical profession, but when you build that wall so high, it can cause issues.

When a physician's quality of care declines, it has historically become a human resources issue, where they address the front-end behavior. We are now working to change the mindset and behavior of just sending the employee to HR and enacting an improvement plan to fix the problem. Instead, we train our physicians to be leaders and influencers who can confidently navigate crucial conversations, professionalism and business planning rather than turning to unacceptable behavior to cope with the stress of their profession.

How do you prevent burnout at Henry Ford Hospital?

I like to think I'm not preventing burnout, but rather building a resilience to it. It's important to be able to adjust in this changing world. I work with three or four generations of doctors, each with different schooling and training experiences.

With our younger doctors coming on board, the biggest anxiety is learning the system. We've adjusted the onboarding process to address the anxiety, introducing new employees to their peers six months prior and using those contacts to facilitate introductions, process explanations and more.

At the other end of the scale, we're developing a program that addresses those physicians transitioning into retirement. How can we evolve and let them serve in a different capacity, continuing to utilize the skills of those individuals without devaluing them? Our answer is to keep them as mentors and consultants.

To address the depersonalization, we have a program with criteria on how to relate to a patient -- how to develop empathy and connect with the patient as a human being. We're building these programs out of effective communication and health care to provide a framework in building healthy habits.

John Billi, MD
Associate Vice President for Medical Affairs, University of Michigan

What does the change from Triple Aim to Quadruple Aim mean for physicians, and how does it address physician burnout?

The Triple Aim -- enhancing patient experience, improving population health and reducing costs -- are established goals to optimize health system performance. Recently, an additional aim was added to address physician burnout. Its focus is to improve the work life of health care providers, including clinicians and staff.

There's an increasing recognition on the cause of physician burnout, with them feeling under a lot of pressure because of the pace of change and requirements to move to electronic records. According to a study conducted by the Mayo Clinic Proceedings, "Burnout and satisfaction with work-life balance in U.S. physicians worsened from 2011 to 2014. More than half of U.S. physicians are experiencing professional burnout."

Many feel as though they are victims of the circumstances they're practicing in, with little control over their environment. Part of the process of moving someone from feeling like a victim of being overworked toward feeling like, "I can fix this, I can change things," is to understand and design experiments to address these problems.

The way to accomplish the first three aims is through an engaged and empowered work force, including physicians and their staff. I feel that adding the fourth aim provides the means to accomplish the first three. If we have a satisfied, productive workforce -- physicians, nurses, therapists and other office staff -- they feel empowered to make change. They can think about ways to make the experience better for the patient and for the physician.

How do physicians address the new goal of improving work life for them and their staff?

I'm a practitioner of lean thinking, or scientific problem solving. I don't think the best way to solve this problem is by hiring efficiency consultants. This is about the physicians and their staff working together on identifying and solving the problems in their office -- whether it's inefficiency in office tasks or even getting your patient in the room on time.

The key method we use is: 1) Go and see, 2) Ask why, 3) Show respect.

Instead of assuming people aren't trying to do a good job at work, understand there are barriers keeping staff from doing that work. I trust staff have the information to design experiments to make a patient's experience or our processes better. This trust empowers my staff to come up with their own solutions, test them out and adjust if necessary.

More employee engagement results in a better working environment, with less stress and better efficiency in providing quality care to our patients.

Where do physicians start in striving for a better work-life balance?

It's all about eliminating the frustrations and inefficient processes that exist in your job or office. While it's important to take time with your family, conduct mindfulness and meditation to reduce stress, it's also imperative to determine a process for coping with workload and other pressures.

Start with the processes in place at your office. Work with your practice's staff to determine what processes aren't working or are taking an excessive amount of time. Are there ways to address those issues? It isn't about errors or blame, but how the staff can design a better and more efficient way to accomplish tasks.

Christine A. Sinsky, MD, FACP
Vice President, Professional Satisfaction, American Medical Association

How does acknowledging the health and wellness of physicians and staff affect a practice as a whole?

Physicians and their care teams thrive when they are well-supported with the knowledge, tools, workflows and policies to do their work most effectively. When they can enjoy their work, patient care is better. When burnout is lower, then quality, safety and satisfaction is higher.

Ironically, both burnout and its opposite -- joy in practice -- are contagious. By addressing the issues that are leading to stress and burnout in staff, ideas and solutions can catch on and spread.

What is the AMA STEPSforward™ program and what value does it offer physicians in regard to burnout in the health care profession?

The goal of STEPSforward™ is to help physicians re-engineer their work so that it is more efficient and effective, thus more satisfying for the patient and for the team. The toolkits offer practical and actionable guidance, including checklists for expanded roles for nurses, calculators to estimate cost savings for a practice, tools to conduct successful team meetings and much more.

There are videos of many of these innovations in action, so you can watch a team meeting, daily huddle, learn more about pre-visit planning or see how team documentation works in practice.

The modules were created by physicians for physicians. They are written with expertise on the topic and reviewed by peers to provide a one-stop resource for physicians and their practices. Since STEPSforward™ launched in June 2015, more than 25,679 modules have been completed.

How can physicians incorporate the AMA STEPSforward™ in their practice?

A good place to start is by filling out the practice assessment questionnaire online. It gives an opportunity to reflect on one's current practice versus what is possible. Based on the responses, specific modules are recommended.

It is often helpful to start with straightforward, relatively simple operational changes, such as instituting pre-visit laboratory testing and synchronized prescription renewals. Each of these strategies creates early wins and can save the practice 30-60 minutes of time per day. It is also helpful to hold team meetings so that medical assistants, nurses, reception staff and physicians can step aside and re-engineer the work to be more efficient and effecting, using the STEPSforward™ modules as a guide.

Hear how other physicians center themselves and strive for that work-life balance:

"Life is so busy and hectic both at work and at home. What really grounds me is yoga and meditation, leading me to deep levels of relaxation that I would otherwise struggle to find."
J. Mark Tuthill, MD

"I try to stay balanced by being involved with activities that are completely non-medical in nature. Whether they are related to community events, social events or my hobbies, they all remind me that life is not 100 percent about my medical practice."
S. Bobby Mukkamala, MD

"The best thing I've done is negotiate structured time off. The week off allows for decompression and I return the next week re-energized."
Tom Veverka, MD, FACS

"I am extremely fortunate to have colleagues that I trust and respect. When I am not the guy on call, I can distance myself from work. My weekdays at work are highly structured to be predictable and productive. This allows me to plan free time to be with friends and family."
Richard C. Schultz, MD

"I love activities in nature -- biking, bird watching, hiking, kayaking and cross country skiing. Recently I've learned more about mindfulness, and my goal is to meditate 10 minutes almost every day."
John E. Billi, MD

"My satisfaction has always been a matter of appropriately prioritizing what's important to me. I believe there is nothing more important than quality time spent with family. For me, satisfaction comes from focusing on the people you love, stayhing positive, helping others and appreciating the blessings in life."
Pino D. Colone, MD

"Look at the big picture. By pursuing useful diversions -- hobbies, exercise, relaxation and spending time with family and friends -- physicians will remain healthy, extend their careers and get greater satisfaction from the practice of medicine."
James C. Mitchiner, MD, MPH

"I have learned to say no. Instead of heaping more on an already full plate, I am delegating and looking for good results instead of perfect results. The parts of my professional life that bring me the most satisfaction are the relationships that have evolved over the past 20 years. The intellectual challenges of practicing medicine helped me set priorities. As I strive to find balance, I am consciously working to be more present in the moment."
Rose M. Ramirez, MD

"Care for yourself so you can serve others. Love your family, laugh, make time for fun, be curious, and try to get to heaven. In the end, no one will say you didn't work enough."
Joann Smith, MD