Lecturing physicians about not burning out is a delicate task, Jennifer Ramsey, MD, noted at the start of a Hospital Medicine 2018 talk on preventing, recognizing, and recovering from burnout.
“I did not want to come up here and be a cheerleader and say, ‘Let's just practice gratitude and we'll all be OK,’” said Dr. Ramsey, who is a critical care specialist at Cleveland Clinic in Ohio. “You can teach a canary in a coal mine to meditate, but he's still going to die.”
To keep hospitalists from getting to levels of burnout that dire, interventions are needed on all levels, from individual clinicians to national organizations. “There are so many people and different parts to this—in addition to physicians, also part of this are the technology vendors, the regulators, the payers, the accreditation agencies, the policymakers, the patients themselves,” said Dr. Ramsey. “All have a piece to play in how to solve this problem.”
She and other speakers at the conference offered their ideas about what some of those pieces might be in a series of talks covering burnout solutions ranging from gratitude journals (which are actually supported by research) to flash mobs and scheduling systems.
From causes to solutions
The factors that have been identified in research on occupational burnout generally may sound familiar to many physicians, Dr. Ramsey said. They include unrealistic workload, loss of control, lack of appropriate rewards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.
She also offered some physician-specific burnout research, from the 2018 Medscape National Physician Burnout & Depression Report. “If we ask physicians what contributes to our burnout, we answered too many bureaucratic tasks and spending too many hours at work,” she said.
The good news is that a number of efforts are underway to combat these challenges, including the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience.
“The National Academy of Medicine absolutely recognizes that most of the contributing factors to burnout are external,” she said.
However, physicians can take some steps to reduce the internal impact including scheduling time for recovery, maintaining a sense of humor, and even feeling gratitude. “Earlier I teased about meditation, but one study showed meditation had an effect equivalent to using a [selective serotonin reuptake inhibitor],” Dr. Ramsey said.
Hospital medicine programs can also take steps to fight burnout. “Develop good bosses and then hold bosses accountable for physicians' emotional well-being, in addition to the financial and quality measures,” Dr. Ramsey recommended, citing a study in the April 2015 Mayo Clinic Proceedings that analyzed the impact of health care leadership on physicians. “For every one-point increase in the measure of leadership, there was a decrease of 3.3% in burnout.”
Her own hospital has assigned a leader to work specifically on the issue, by creating an office of caregiver experience.
Hospitalist programs may also be able to increase physicians' sense of control and community, she suggested. “Can we protect 20% of our time to devote to work that we're passionate about?...Or if we're not going to have doctors' lounges, can we physicians have some space with computers and free food and seats where we can run into each other and talk?”
Physicians could also be encouraged to take more time off work. “Our paycheck might be decreased if we don't take our vacation time—pretty neat,” said Dr. Ramsey. “Maybe we should think about which carrot to dangle. It may be a simple solution for leaders to say ‘I'll just give you more money,’ but maybe what's more needed or more appreciated is flexibility or protected time.”
One such experiment at the Stanford School of Medicine created a “time bank” to recognize faculty for time spent on tasks like committee membership. “The reward was anything from having a meal delivered to the physician's home to dry cleaning services, housecleaning services, or having somebody help write a grant,” said Dr. Ramsey. Female faculty members were the biggest users of the time bank, and twice as many of them reported feeling supported at work after the pilot, according to a perspective published in the New England Journal of Medicine on Jan. 25.
“On the organizational level, lots of little really cool pilot programs [are] going on around the nation,” said Dr. Ramsey.
A program of pilots
At least one hospital medicine program has implemented a lot of these programs. At the conference, Patrick Kneeland, MD, executive medical director for patient and provider experience at UCHealth, described the University of Colorado division of hospital medicine's organizational approach.
In 2013, the group's leaders began researching solutions to burnout, including conducting an initial culture survey of the staff. “As soon as you start measuring something, you're actually signaling that it's important,” said Dr. Kneeland. “Say, ‘We actually want to know, how are you doing with things like work/life balance? How are you doing with professional development? How are you doing with your sense of collegiality?’ All of the sudden you're changing the conversation.”
The survey was repeated every year to measure the effects of the interventions, which have been implemented gradually since 2014. An early one was the creation of “above and beyond” awards. Winners are nominated by their colleagues and receive a $5 coffee gift card and recognition in an all-staff email. “At first, it was met with some skepticism...but it really took off,” said Dr. Kneeland.
His colleague Read Pierce, MD, noted that although the program seemed popular (with more than 200 awardees to date), most winners never picked up their coffee cards. “When we asked them why, they're like, ‘It's not about the coffee card. I want the validation of hearing my peers say you were awesome.’”
Another intervention focused specifically on awe. “We decided that there are so many cool things going on in our environment every day. And how often are we recognizing those things?” said Dr. Kneeland. Since 2017, the first five minutes of every faculty meeting have started with a story. “People brought all kinds of incredible stories to the table,” he said. “It spread somewhat organically to some other leadership meetings in our group and external to our group as well.”
Multiple interventions have focused on closer communication between leaders and front-line staff, including leadership rounds and flash mobs. The latter is a novel method to gather all staff and quickly analyze recent events on the wards. “If all of the sudden we're experiencing twice the normal volume, for example, we might have a flash mob to dissect what's going on with our workflow, how are people doing?” explained Dr. Kneeland.
Other changes encouraged clinicians to support each other, for example, the 2016 creation of a faculty coaching program for new hires: “Anything from practical questions, like ‘My login's not working’ or ‘How do I page [interventional radiology]?’ all the way through to ‘I just need to debrief this thing that happened today,” said Dr. Kneeland.
The division's annual review was also revamped, more leadership roles were created, policies on use of CME funding were revised, and a parental leave task force was formed (resulting in a formal leave program and breastfeeding space). Scheduling was redesigned in 2016. “We landed on something that was appropriate for our group in terms of a balance...but that conversation goes on forever. This is actually an ongoing dialogue,” Dr. Kneeland noted.
The culture surveys have showed ongoing progress toward the program's goals. Only 33% of clinicians reported feeling burned out in 2017, compared to 44% in 2014, despite increases in patient volume. “We were a little bit surprised,” Dr. Kneeland said. “As the pressures seemed to be intensifying, as the complexity was growing, we actually reduced burnout.”
Staff turnover also dropped, from 13.2% in 2009 to 2013 to 6.6% in 2014 to 2017. “We actually went back and calculated the savings from that, and a conservative estimate is about $500,000, so we're really proud of that,” he said.
Most of the interventions were low- to no-cost, Dr. Pierce noted. “This was actually an incredibly lean process financially,” he said. However, the program leaders are looking at a more expensive change for 2018: increasing the equity of salaries and shifts. “That's going to be a really expensive, seven-figure kind of investment, but we've made the case for why it's going to matter,” said Dr. Pierce.
Shift designs matter quite a lot in burnout prevention, agreed the speakers in a panel discussion on how schedules impact hospitalists' lives and burnout.
“My opinion is that the more you can introduce flexibility into your schedule, the more you feel in control of your schedule and your work life,” said John R. Nelson, MD, FACP, medical director at Overlake Hospital in Bellevue, Wash., and a hospitalist practice management consultant.
Although seven-on/seven-off remains the most popular hospitalist schedule, it doesn't support such flexibility, Dr. Nelson asserted.
“When you decide when to take your camping trip with your family this summer, you get out a calendar and you say,...’OK, there's a week in July that I'm off, let's go then,’” he said. “If you have a flexible schedule, you can turn that around, and instead of the first thing on your calendar being the weeks that you work, the first thing you put on your calendar can be ‘Here's a camping trip I'd like to take ... Here's a Wednesday I want to be off, because my son's soccer tournament is that day.’”
Flexible schedules are also helpful for academic programs, added Eric Howell, MD, division director of the collaborative inpatient medicine service at Johns Hopkins Bayview Medical Center in Baltimore. “Faculty have to teach, go to class, do research projects. If they had seven-on/seven-off, half their life they wouldn't be able to do that Thursday group,” for example, he said.
The problem with flexible schedules is that they're much more complicated for administrators, countered Meredith Wold, PA-C, advanced practice clinician supervisor for hospital medicine and critical care at Regions Hospital in St. Paul, Minn. “When we make schedules twice a year, that's a very daunting task, so the rigidity that comes with being able to extrapolate your schedule out months in advance is a benefit from a supervisor and an administration standpoint,” she said.
Software systems can help with the more complex schedules, Dr. Nelson suggested. “That may be a very worthwhile investment if it's in the interest of well-being and career longevity of providers,” he said.
Physician and administrative preferences also conflict when it comes to shift length, Dr. Howell noted. “What I hear from my clinicians is that they really like 12-hour shifts, because they can do fewer shifts with longer hours, but from an administrative point of view, the 12-hour shift has a decreasing value at the end of the day,” he said.
It's preferable to have at least some physician shifts scheduled for only 10 hours, Dr. Howell added. “That's short enough so that people don't get totally fatigued and long enough so that they can get a lot of work done in 10 hours. Usually we find that 8-hour shifts are just 10-hour shifts anyway, so people feel like they are being cheated.”
Clinicians can also get upset if they feel like their shift length is unnecessarily rigid, according to Dr. Nelson. “It's always kind of felt clunky to me that so many groups will specify right in the contract exactly how long your daytime shift is, for example, 7 a.m. to 7 p.m. in very many groups,” he said. “You should leave at 5 if it's not busy and you're performing well. There should be no reason why anybody thinks it's good management to have you stay.”
“I don't like clock punching either, but one thing to recognize is that it's a team sport,” Dr. Howell responded. “The fast people leave early and the plodders stay late, and there's always a problem sooner or later, and guess who's in house when there's a problem?...You don't want to punish the plodders for being in-house, and you don't necessarily want to punish the people who leave early, but there has to be a way for them to be able to work together as a team.”
Full schedule autonomy might not work for every clinician and some counseling might be required, agreed Dr. Nelson, but he stuck to his support for flexible day shifts, offering another example of the potential advantages.
“If you tell your group ‘We start work at 7 a.m., but we want early discharge orders, so somebody has to come in at 6:30,’ there's going to be a riot,” he said. “Reframe that and say ‘We want early discharges; I don't care how you achieve that.’” With that instruction, some physicians may prepare their discharges the night before and others may come to work early, he said.
Variable start and end times fit into Dr. Nelson's overall perspective on physician burnout. “I think rigidity over long periods of time becomes stressful in anything you're talking about. Any variable in our lives, if it's always the same, it becomes distressing,” he said.
Dr. Howell was not entirely convinced (“I think some people like monotony, to be honest,” he said), but the two hospitalist leaders did manage to agree on a final key piece of advice for preventing clinician burnout. “Being able to be flexible to meet the needs of the most people, depending on the culture of your program, is important,” Dr. Howell concluded.