Burnout & Solutions in Health Care

A recent roundtable was had at NEJM Catalyst and the subject was physician burnout. This is a topic that affects us all, health care practitioners, patients, carers, policy makers and the public at large. Because our health is at risk, all of ours.

“Burnout is an indication of underlying organisational dysfunction. Effectively addressing burnout requires a comprehensive strategy that operates at the enterprise, departmental and individual levels.”

I’d like to share a short summary and add my thoughts, especially regarding burnout as a symptom and the role that individuals have to play in all this.

So yes, we have a symptom, now what do we do?

1.     You need to diagnose before you can cure. The first step the authors agree is measuring key indicators. And this is not a one-off exercise, you have to check in on a regular basis. Kind of like going to your GP. The roundtable suggests exploring manifestations, drivers and impact of burnout. As I see it, burnout is a symptom of an underlying disease. Burnt out, dropped out and suicidal doctors are merely the tip of the iceberg, or as Maslach aptly states ‘the canary in the coal mine’. Far from suggesting the individual canary is just not fit enough, I believe the only solution to the underlying disease – which undoubtedly is a systemic one – lies on an individual level. After all, the easiest, and equally the most difficult, yet the only thing you ever can change is yourself. Any meaningful change ever effected started with an individual, so yes, effecting systemic change starts with oneself. This is a call to action for all individuals that make up a system, in other words a call to all of us.

2.     The roundtable indicates that after having identified the situation and its barriers (or the symptoms and the underlying disease), the second step then is to address these findings by designing what they call a burnout mitigation plan (or shall we say a prevention & treatment plan). This plan is comprised of a multi-tiered approach: supporting physician wellness, changing the management system, and improving efficiency in care so as to enable healthcare professionals to focus on the patients. Which is what most of us probably set out to do in the first place.

So, I’d like to elaborate on each of these points:

·      Supporting physician wellness. This, I believe is a crucial point. Because everyone is equipped to address their own level of wellness and improve upon it. In fact, it is a responsibility we have towards ourselves to make sure we keep as well as we can. If we aren’t responsible then who is? Learning about stress, burnout, it’s causes and effects, and learning how to mitigate and protect ourselves from harm is paramount. Becoming more mindful of our own behaviours, thoughts, emotions, values and drivers is absolutely crucial to understanding and helping ourselves, let alone others. How can we fix things, if we can’t fix ourselves? I firmly believe we need to have our oxygen masks on first before we can help others put theirs on. And as seasoned campaigners in health care it is our responsibility to teach these principles to patients and to colleagues.

·      Changing the management system. Management is one aspect, the really important point, though, is leadership. Good leadership is called for. Good leaders, too, start with themselves, as they lead by example. They have self-awareness, courage, they show up, they speak up, they ensure they are heard, they listen, they are prepared to engage with the difficult and the unpleasant, they pick themselves up when they fall, they admit their shortcomings while giving blame and shame a rest, and they tolerate uncertainty in themselves and others. They collaborate, they encourage creativity and thinking outside the box, they give and receive feedback constructively, they’re willing to give other people the benefit of the doubt and let them try new ways of doing things. By leadership I mean people willing to have each other’s backs while we are collectively doing our best to work this out. Good leadership on all levels of an organisation will lead to benefits for the entire organisation. And in case you were wondering, leadership is not tied to a role, it is a mindset, a way of being.

·      Improving efficiency in care. The last point will undoubtedly include technology and the use of big data which is all very exciting. Examples of how to improve efficiency include digital solutions to streamline workflow management, design straightforward and user-friendly electronic health care records, facilitate timely and accurate communication, improve standardised sharing of knowledge, implement patient symptom tracking (devices) and integrate patient reported outcome measures & need assessments, as well as overall improvement of teamwork and care coordination. Interestingly, the NEJM Catalyst survey indicated that the top two suggestions for reducing burnout were delegation of clerical tasks and improved IT solutions. So, this appears a call to arms for the world of technology in service of health care.

3.     The third step that the roundtable participants proposed is to implement some sort of feedback cycle to make sure what was started stays on track (in medical terms ongoing follow-up care). A sound suggestion, that I believe is often not installed longer term. There are many models and variations of ‘the feedback loop’. Suffice to say, you develop a plan or goal, put it into action, check how it’s going and then adapt and improve as you go. And over and over and over and over, you get the gist... The exact ‘why, what, how, when, where and by whom’ aspects are best decided by the people directly involved.

If done well, over time these steps will lead to a culture change (eradication of the underlying disease) of the health care system. The thing about complex systems is that if you stay in a system long enough, one of two things will happen. Either the system changes you, or you change the system (Ashby, R.). So, if you choose to step up, become aware, change your behaviour, then engage others so they become aware and change their behaviour, and if enough people begin and keep on doing this well, then eventually the tipping point is reached, things start gaining momentum and the system begins to change. This is a multi-step process and it takes time, blood, sweat and tears, yet it is the only way anything ever has changed. And, I think our collective health is surely worth the ongoing effort. Lastly, if there is only one thing you take away from this, then let it be this. You may not always be directly responsible for what is, however you are part of a system and purposeful change always, always starts with YOU!

Find the full NEJM Catalyst roundtable report here.

Changing the culture of bad behaviour @ work

Bad behaviour in the workplace can run up high costs in terms of reduced productivity, wellbeing, mental health, missed days at work and loss of revenue. In other words, it affects the bottom line of business, not to mention perpetuating individual suffering. Therefore, it would seem organisations and industries would be well advised to address both ‘misbehaving’ individuals, and the broader issue of culture change, designed towards eradicating such behaviours as mobbing, bullying and some of the less obvious ones; i.e. selective exclusion of individuals from groups, stringing people along, or purposefully assigning tedious and meaningless tasks.

Recently, I’ve been involved in running immersive workshops on the subject of bullying, and developing strategies of how to manage a badly behaving colleague at work. Lively and often critical discussions arose amongst the participants; particularly, around the usefulness of the bullied person experimenting with and learning how to deal with a bully, versus having someone in the higher echelons come in, ‘sort out’ the bully and generally get bullies to behave better.

Now, of course much depends on the person being bullied and their relationship with the perpetrator. And, please keep in mind that I am exclusively speaking of adults, here, not children. Admittedly, however, often there will be a power differential or dependence that facilitates bullying in the first place, which can make it all the more difficult to call out and put a stop to. So, far from suggesting the bullied person should just ‘take’ the behaviour and get some form of support, later, I do firmly believe we can only control our own behaviour, not someone else’s. And, I also firmly believe if our aim is culture change at large, misbehaviour needs to addressed at all levels - from the top to the bottom of the totem pole. Let me explain.

If the aim is to change a bad culture in the workplace, I believe we all must change our own behaviour first. Much as I wish this for myself sometimes, we cannot count on someone else to put a stop to unpleasant things for us. And once again I am talking about adults, here. I will also briefly mention a bright and little-known researcher and psychiatrist by the name of W. Ross Ashby (also see Requisite Variety and Cybernetics), who described way back in the 1960ies that if you can’t change the system; the system changes you. And, I reckon the same goes for culture.

So, I’ve come to the following conclusions:

1. Change our own behaviour we can, other’s behaviour we cannot.
2. We can learn to stand up for ourselves, and sometimes this might mean losing a battle to win the war.
3. We can respectfully insist on being treated by others with due respect.
4. We can set a good example by treating people with more respect and kindness than they perhaps deserve. I believe cutting others some slack and treating them respectfully breeds kindness and respect in return… You know, the whole yelling into, and echo coming out of the woods thing….
5. By all means, engage others such as colleagues, peers, trusted superiors, and friendly people at the HR department to assist in these matters. I am not suggesting this need be or should have to be shouldered alone, not at all.
6. We can choose to speak up for those who don’t, won’t or can’t speak for themselves.
7. Together we can continue the conversation, create awareness and speak to policy makers, CEO’s, directors, superiors and HR representatives, and thus start changing the culture - the system - which will in turn impact individual people within that system, both bullies and the bullied.

So, the workshops on dealing with bad behaviour in the workplace are not meant, nor could they ever be, the be all and end all, the one and only solution to this cultural and systemic issue. As all the workshops I run, they are meant to get people thinking, and talking to one another. They are meant to let people experiment with - in the safe workshop space - how they might choose to behave on an individual level when they find themselves in such a situation. And, perhaps most importantly these workshops are intended to challenge perspectives, to slightly rattle people to incentivise them to take action towards change. And, if we have only in a little part succeeded in doing that, then I would say ‘mission accomplished’.

If you are interested in learning more about these workshops please get in touch here for all workplaces and / or here for the health care sector. Thank you.

Serious Woo - addressing elephants in the room

There's an elephant in the room!

Mental health issues occur quite often in the general population. Depending on the source around 1 in 5 people will have to deal with a mental health issue sometime in their life. So, it is very likely that any one of us will come across this sooner or later, either in someone we know or in ourselves. And it is a given that a number of people in the workplace will be dealing with mental health issues.

Therefore, it is helpful to gain an understanding about mental health issues, be able to better recognise when someone is suffering from a mental health issue, and know how to respond and support the person in getting qualified help. Knowing what to do in theory, and doing it in the heat of the moment, are two quite different things. Therefore, it is extremely useful to participate in an experiential learning course, where participants get the opportunity to practice communication around addressing elephants in the room, before they might have to do so in real-life.

I would like to shout out to the wonderful people at Serious Woo - many of whom I know and can personally recommend - for offering this course in the workplace and corporate space. The course is run by Serious Woo involving professional role-play actors and knowledgeable, highly experienced psychotherapists and facilitators for an engaging experience. For further inquiry and to book a course please contact Serious Woo at:

http://docs.wixstatic.com/ugd/214c7e_4b356f0b0d794a17bb9168abe619d2a2.pdf

or

www.seriouswoo.com.au 

Working in the trenches - Mindset & Resilience

A little while ago, I was talking to a fellow doctor. One of those who describes herself as an elder, or should I say a seasoned individual with a track record of having been in the trenches and seen the better part of the human (mis-)behavioural spectrum. We both agreed that our experiences can and should be used towards helping younger colleagues navigate some of the joys and pitfalls of working life, particularly in the medical profession. And along those lines, we asked ourselves how resilience can be built amongst health care professionals, and in extension amongst people in general.

Resilience is commonly defined as the ability to bounce back in the face of setbacks, failures, disappointments and mistakes. And, I believe one of the biggest barriers to resilience - particularly amongst doctors - is the prevailing 'fixed mindset' (as described by Carol Dweck). This describes a mindset that is very outcome orientated, an all or nothing, black or white view of the world. This mindset is very common, I daresay especially in people who tend towards being perfectionistic, and in my experience there are a fair few of those working in hospitals and practices, near and far. But really, I think this applies to anyone who has a perfectionistic streak. And, these individuals typically fear not getting it right, and making mistakes more than anything. Being anything less than perfect is perceived as catastrophic for them and for the people this may affect. They would have let themselves and everybody else down. How do I know this? Well, take a wild guess;)

The problem is that we all know we are not perfect, nor free from making mistakes. On an intellectual level we understand this, yet, when it happens it feels terrible. Even to the point where it might discourage us from ever trying that particular thing again or moving beyond our comfort zone and trying something we might be less then perfect at. And with that our lives shrink, become smaller and smaller, and definitely less adventurous. Which is a shame. Really.

On the other hand, there are people with a growth mindset (check out Carol Dweck - it's good stuff) who learn by making mistakes. And yes, there are a few of these people working in medicine, too. They go out and experiment, they go take a leap, knowing that there is a possibility for a rocky landing. Picture that! And when and if they land in a heap on the floor, they not only pick themselves back up, but they bounce back. They try again, they try better, and yes, occasionally they fail better. And of course eventually they succeed, and in doing so they grow, they become better than they were before. And I think that is a wonderful headspace to be in.

So how do we as the elders, the youngsters and everyone in-between, create such a health care culture where minds are open, where resilience and support are strong? The good news is everyone can learn to grow a growth mindset, and by doing this, improve their resilience. You can start small, and test the waters. And, you can set up 'safe to fail experiments', in other words small challenges where a crash landing is not life threatening. But you just might find it to be life altering, in a good way. You can orchestrate your environment such that you are supported by people who have done this before and who can cheer you on along the way, and help pick up the pieces when it doesn't go to plan. And this is where elders, experienced colleagues, supportive friends, family, and professionals can be of great help. People who can hold you accountable for challenging yourself with such experiments, and offer support and encouragement where needed. So, from my view as a friend, a family member and a professional, it is in everyone's interest, and it is our shared responsibility to co-create environments that are supportive of individuals who are willing to engage, experiment, contribute and not be blamed and shamed if they occasionally get it wrong. It is important to have each other's backs! And I reckon, the sense of feeling safe to fail and not be draconically sanctioned for any and every misstep will in itself promote more successful endeavours.

Diagnose before you prescribe

It is no secret that I am a fan of Steven Covey's book 'The 7 habits of highly effective people'. I find there is a lot of very useful stuff in there. One of the things that really struck me, is his description of the importance of listening in order to understand - truly understand - someone else, both emotionally and intellectually. This also has been described elsewhere as affective and cognitive empathy.

Covey uses the analogy 'diagnose before you prescribe', and as a doctor that really makes sense to me. We've learned to take a history, then examine, come up with differential diagnoses, conduct further testing as necessary, before lastly prescribing and treating. Jumping to conclusions too quickly can have disastrous effects in medicine, and the same goes for communication. If we assume we know what the other person really means, when actually we don't, at best we run the risk of leaving the person feeling misunderstood. And worse, possibly create an opening for further misunderstandings and mistakes. Lastly, it is a missed opportunity to truly connect, and perhaps a missed opportunity to come up with a 'prescription' that both parties can live with, metaphorically speaking.

So, I dare you to imagine what could happen if we all spoke a little less, and listened a little more intently, and with a little more heart...

Thank you.

A big thank you goes to everyone who took the time to look at this website, and share constructive suggestions, thoughts and impressions.

One point has come up, which I would like to answer. Why is the Harbour Bridge everywhere on this site? Well, I really like that bridge, it is a magnificent and powerful work of construction. Its view greets me day and night, and I can tell which way the wind is blowing and how strong by looking at the two flags atop. Yes, and sometimes I can make out the brave bridge climbers up on the arch. In brief, it represents Sydney. Also, it is a great metaphor for both coaching and communication. A developmental coach aims to help the client (coachee) build a bridge between where the coachee currently is, and where it is that she or he wants to go. And 'building bridges' between people and ideas, is a hallmark of good communication.

So, once again, thanks! I truly appreciate your thoughts and comments, and please keep them coming.