BY: MALCOLM HERRING, MD, RACHEL FORBES KAUFMAN and RICHARD BOGUE, PhD, FACHE
"The man who places himself in the care of a doctor is something more than nerves and tissue, blood and organs. And though the doctor is called in directly to heal the body, he must often give advice, make decisions, formulate principles that affect the spirit of man and his eternal destiny."
— Pope Pius XII, January 30, 1945, "Address to Physicians"
The importance of a person's spirit and eternal destiny are eclipsed in American medicine. The most alarming effect of this eclipse is that the prevalence of burnout among physicians is high (about 46 percent) and growing.1 It is alarming because trends that deplete the physician's spirit tragically impair the physician's capacity as a healer and as one who renews the spirit.
Serious and persistent burnout is a condition characterized by emotional exhaustion, depersonalization of patients and ineffectiveness. Without deliberate intervention, burnout can threaten the health and well-being of the physician as well as his or her patients and their families.
Of particular note for patients is the well-documented adverse effect of burnout on medical decision-making. In an excellent review of the problem, the authors pointed to numerous issues that afflict physicians: health care reform, performance-based reimbursement, changing care models, the electronic medical record, the new diagnostic coding system, increased training requirements, "hassling" by insurance companies, obtuse pre-authorization criteria, proprietary health care, personal debt, family demands, the emotional consequences of treatment failures and patient losses.2 Any one of these stresses is bad enough, but the litany overwhelms. And burnout can lead to adverse medical events, emotional exhaustion and dehumanization of patients.
Compared to other professionals, studies show that physicians disproportionately struggle with work-life balance and report symptoms of burnout, some with severe emotional exhaustion. Some think about taking their own life; others do it. "Physician" is among the occupations with the highest rates of suicide, according to the National Institute of Occupational Safety and Health.
Meanwhile, the demand for health care services is increasing. The Affordable Care Act has given millions more people access to health care services, and the baby boomer generation is aging — a group that includes plenty of practicing physicians who are contemplating retirement or greatly reducing their workload.
CATHOLIC IDENTITY AND HEALING
Catholic identity finds its root in the life, healing and teaching of Jesus Christ and bids us make visible the works of God. We are created by God, we are good and we are appointed for good works. We are good when we act out of the divinely appointed true self, rather than out of our culturally created false self. Our true self is, by its appointment, in a right relationship with God and longs to help others restore their own right relationship. That restoration is the Christian concept of healing.
Critical to Catholic health care, Catholic identity bids us to minister directly to the needs of individual physicians, helping them find restoration, protection, resilience and balance for their lives. Because restoration is at the center of Catholic identity, this ministry is a responsibility rather than an option.
As much as we might want our physicians to be superhuman, they are just as human as everyone else. Yet they are trained to defer gratification, ignore personal needs and put the patient first. Already rife with stresses, they enter their practices seeking perfection. That burnout rates are high is hardly surprising, but it is burnout that can lead to adverse medical events, emotional exhaustion and dehumanization of patients.
MENTORING
The Coalition for Physician Well-Being, an association of faith-based health care systems, hospitals, individuals and professional organizations, St. Vincent Hospital and Health Care and the St. Vincent Medical Group, Indianapolis, Indiana, are performing a randomized trial of a clinical pastoral care model of peer coaching called Life Centered Mentoring.
Using validated metrics, namely the Maslach Burnout Inventory and the recently developed Physician Well-Being Self-Assessment Test, the St. Vincent study is testing the effect of Life Centered Mentoring on patient experience as measured by satisfaction scores. The thinking is, if physicians are spiritually, emotionally and physically well, it will translate to improved patient experiences.
Physician attitudes about their identity and their work are deep and personal. Peer mentoring has been criticized as a model because physicians are usually very busy, and they aren't trained in psychotherapy — contentions that are indeed true. However, physicians tend to listen to physicians because they walk the same professional road. And Life Centered Mentoring is not psychotherapy, it is a collaborative relationship, peer coaching for and by physicians, under the supervision of someone certified in pastoral care.
On every medical staff there probably are physicians willing to serve as mentors, and some of them will prove to be very good at it. Their service helps form a medical staff culture of mutual care and compassion, and it reduces the isolation that burned-out physicians report. Moreover, close mentoring relationships are more likely to identify physicians who are at risk.
Physicians often regard themselves as medical marines, tough and independent. They have all the problems that everyone else has, but they often lack much social support, and they won't seek out a mentor, especially if they don't see mentoring occurring for any of their colleagues. Under the Life Centered Mentoring model, physicians are invited to participate when they have just recently joined a group or a medical staff. These new physicians are not encumbered by cultural baggage, and they are the ones most open to new practices.
Much of the mentoring is done in hospitals and clinics, informally, and it can apply during many circumstances in a physician's career. Mentoring has been helpful for times when a marriage is shaky, when one of the kids is on drugs or during bereavement. Mentoring also can help a physician learn a new therapy, or how to be a team leader, or how to make the transition to administration.
Mentoring has been around for many years and is used primarily for skill training or to remediate a problem. In contrast, Life Centered Mentoring is holistic. It addresses physician burnout and inspires sustainable strategies through self-discovery. These are strategies that keep physicians engaged with their purpose for entering the practice of medicine in the first place.
Mentoring conversations are focused and supportive, flexible enough to allow participants to explore ideas and strategies born out of their own experiences, personalities and faith traditions. Yet the conversations are structured enough to guide the participant through topics that are important for burnout prevention, for the development of resilience, and for the creation of "margin," that is, space. The goal is to allow physicians to discover their divinely appointed selves and truly to become healers.
SUPERVISORS AND MENTORS
Physician-supervisors undergo training and certification at Saint Meinrad Seminary and School of Theology in St. Meinrad, Indiana. There, they learn pastoral theories, models and skills necessary for effective reflective practice. Included are two one-week seminars and one year of field training. The supervisor does most of the matching of mentors and protégés, but it is the responsibility of everyone in the program to be sure the matches are working.
The supervisor also is the mentor to the mentors, meeting with them about once a month and helping them to hone their skills and manage mentoring issues that come up. In turn, the physician-mentors will be better able to model the language and encouragement that the new physician-protégés need to confidently engage with the spiritual questions that naturally arise at the bedside.
A good mentor candidate should be mature, esteemed by physicians and nurses, have a strong faith and have a strong commitment to the project. The way physicians are trained provides tools for mentoring — they talk to patients all the time — but Life Centered Mentoring training helps physician-mentors develop the all-important art of medicine, which exercises skills of compassion. That means listening with the heart and not just the intellect; becoming more aware of one's own body language; identifying useful open-ended questions; and learning to sit comfortably with patients during some of the most challenging times of life. The patient's spirituality is a legitimate component of healing. New mentors are coached carefully about how to open the door to spiritual conversation and reflection, developing a language for discussing spiritual questions and experiences.
The schedule for Life Centered Mentoring sessions is six one-hour sessions that occur two to three weeks apart. The sessions are guided, but not scripted, conversations designed to establish a relationship that encourages both participants to explore strategies for achieving work-life balance, financial margin, emotional margin and physical margin. Finally, the pair considers what steps to take after the sessions conclude.
Jennifer Stanley, MD, is a supervising mentor. She says that although she was torn about taking on the project, she is glad she did. "This work is going to be a powerful way for us as physicians to connect with our colleagues over a topic we all hold dear to our hearts — healing," she said. "We have to take care of ourselves if we're going to turn around and take care of our communities."
Stanley further reflected on the Saint Meinrad training and the mentoring practicum: "I didn't realize how much I would be challenged and grow myself," she said. "It has been a pleasant surprise. I've re-engaged with my purpose; the mentoring opportunities have 'filled my cup,' and I am so much happier."
On the project team for Life Centered Mentoring, MALCOLM HERRING is study designer, RACHEL FORBES KAUFMAN is project manager and RICHARD BOGUE is research methodologist, https://sites.google.com/site/lifecenteredmentor/home.
NOTES
- Tait D. Shanafelt et al, "Burnout and Satisfaction with Work-Life Balance among U.S. Physicians Relative to the General U.S. Population," Archives of Internal Medicine 172, no. 18 (Feb. 8, 2012): 1-9.
- Michael R. Privitera et al., "Physician Burnout and Occupational Stress: An Inconvenient Truth with Unintended Consequences," Journal of Hospital Administration 4, no. 1 (February 2015): 1-25. www.sciedu.ca/journal/index.php/jha/article/view/5616/3589.
BLINDSIDED
I hadn't talked to Walt for several weeks. He'd been alone at home. There were guns in the house. His memorial service at the hospital was packed. People who worked alongside Walt talked softly about how wonderful he was and about their shock at the violence of his death. What should we have done? Why could we not help him? I thought back.
I met Walt when he was a cardiology fellow. His star rose quickly, and he emerged on the national scene. He was always dressed in his scrub suit, protective lead apron and thyroid shield. I rarely saw him outside the clinic, but when I did, I realized that he had very good taste in clothing and automobiles. After 15 years, the lead protection damaged a cervical disc. He required an operation and suffered a stroke. After a long rehabilitation, he came back to work, but he could never wear the lead again. He consulted a little, but Walt's disability strangled family relationships. How do we identify colleagues at risk?
— Excerpt from The Physician Champion, by Malcolm Herring
(New York: Lantern Press, 2010).
MINUTES BEFORE
Ray had seen that look countless times before. She was on a gurney in the pre-operative holding area, separated from the other suffering humanity by white curtains on either side.
Ray drummed up all of the optimism he could. "Good morning, Eloise. How are you this morning?"
"Uh … OK, Doc."
"Have you had any problems since I saw you in the office last week?"
"No. I've been OK."
"It looks like all of your laboratory tests were favorable for today's surgery. I just want to review the plans for today. I will remove an aneurysm from your aorta and bypass a blockage in the artery to your left kidney. Dr. Boyer will remove your right kidney that has a cancer in it. Is that what you understand?"
"Yes. … Doc, it sounds pretty serious. Is it?"
"You remember our conversation in the office. The operation is major surgery, but I'm optimistic about the outcome."
"OK Doc."
The eyes always betray anxiety. Their conversation hadn't diminished Eloise's anxiety. Ray sensed her turmoil in ways he could never explain. Then an idea abruptly occurred to him. "Would you like me to pray for you?"
"Would you?" She looked up and her face began to open with hope.
"Yes, of course." He cupped his hand gently over hers. "Lord, grant Eloise strength, healing and the joy of knowing that you love her. Comfort her family and guide all of the caregivers today. Amen."
He looked down at her. Her eyes slowly opened, disclosing a peace that surprised Ray. "Are you OK, Eloise?"
"Thank you, Doctor," she managed to say. She squeezed his hand like it was her lifeline. In a way it was.
— Excerpt from The Physician Champion