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.

Team Psychology versus Team Medicine, score 1:0

Currently, I am involved in running a mindfulness & stress reduction workshop in the world of medicine. Around that a few interesting dialogues ensued regarding the way we think, teach and learn, and I have gained a few insights that I'd like to share. Oh, also the soccer world cup is on, so...

Medicine, much like psychology over the better part of last century, was very much enamoured with looking for flaws, looking for symptoms, stuff that wasn't working right and then fixing it. In doing so, the goal was to get a person back to normal functioning (however that may be defined). So, if normal were a horizontal line, psychology and medicine are largely concerned with what lies below that line. These specialities deal with disease or shall I say dis-ease.

Over the last 20+ years a bunch a psychologists started looking at what happens above the line, in other words what makes people thrive, excel, and rise above the norm. They decided that what makes human experience extraordinary or über-normal is just as important to understand, research, teach and support. Hence, positive psychology was born. A science concerned with what enables people to be at-ease, to flourish and be in the flow. Interestingly when your focus starts to shift from what is broken to what is working, from your shortcomings to your strengths, then strange things start to happen. Things begin to shift. Your spectrum of options starts to open up, you start seeing solutions where before there where only problems. You become more creative and flexible. Becoming aware of, and deliberately seeking out positive emotions breeds more positivity. Think going to see a funny movie as opposed to a drama, doing things that make you laugh, smile, be merry. Looking for the good moments throughout your day and relishing those. Deliberately putting yourself in the path of fun is actually a very worthwhile thing to do for your health. The cultivation of positive emotions not only breeds more positive emotions but also buffers against the negative ones (yes including stress, physiological stress response and subsequently disease). Now if this all sounds too simplistic, or simply too good to be true, rest assured that this is scientifically proven. There is evidence for this, even using physiological measures of stress (check out Barbara Fredrickson's work and her Broaden & Build Theory).

Sadly, Western medicine is a bit slow to catch on. So yes, 1:0 for Psychology! Luckily, however, there are services popping up in health care that take a more holistic view of providing care. It no longer is only about fixing things, but also about ensuring optimal wellbeing on top of the fixing of dis-ease. The focus is on enabling people to be as much at-ease as possible whatever their story. And of course, that makes sense. If something is malfunctioning it needs fixing. In addition though why would you not do your utmost to ensure that all other systems are in place to optimise overall well-being, sleep, nutrition, exercise, a mind at ease, emotional & social support, spiritual wellbeing and self-care & compassion.

And here lies the thought I really want to drive home. Why wait until you have dis-ease to start using these powerful tools? We all could use a bit more self-care, self-compassion and cultivation of the positive in our lives. So, I invite you to take a pen & paper and spend the next five minutes writing down what those tools are that help you thrive? And how and when you intend to use them?

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...