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.
