BY: TED HAMILTON, MD, MBA
Within the medical community, there is growing awareness of professional burnout. A substantial body of recently published research attests to the scope, prevalence, severity and deleterious impact of this condition. Hospitals and professional organizations are beginning to acknowledge the problem and seek solutions.1
Webster defines burnout as "the point at which missile fuel is all burnt up." Alternate meanings include "damage caused by overheating," or "a state of emotional exhaustion." Somehow all three definitions seem applicable to the malaise and discontent many physicians experience. They are emotionally exhausted, having yielded personal need for rest, recreation and relationship to the relentless demands of medical practice.
A large study that was reported in a 2012 article in the Archives of Internal Medicine described the prevalence of burnout among physicians as "alarming." It noted that primary care physicians (family medicine, general internal medicine, emergency medicine) appear to be at highest risk. Unfortunately, the authors concluded, there is little evidence on how best to address the issue.2
Adventist Health System (AHS), a faith-based system headquartered in Altamonte Springs, Fla., with facilities in 10 states, has been working for a dozen years on ways to support and encourage its medical staff and to combat physician burnout. The undertaking was small at first: a psychologist and a chaplain, employed on a part-time basis, provided what became known as Physician Support Services (PSS), a department of Florida Hospital, the 2,000-bed flagship hospital of AHS that has an active medical staff of about 1,000 physicians.
The basic idea was to provide Florida Hospital physicians with services similar to those of an employee assistance program. PSS counseling services are private and confidential. Initial visits are provided without charge to the physician. The program gained considerable traction when, after about two years, individual interviews with PSS staff became a mandatory part of onboarding for new members of the medical staff. The interviews were low-key, designed to let physicians know about the confidential services, talk about health and self-care practices and encourage the physician "to tap into resources to support growth and development. Self-care is presented not as an option but as a best practice."3
Over the past decade, about 600 physicians have accessed PSS counseling resources, resulting in over 10,000 visits for a variety of complaints and conditions. Most common among them: anxiety and depression, marital and family stress, anger and boundary issues, addiction and substance abuse. Over 90 percent of referrals to physician support services are voluntary and self-initiated.
Over time, PSS has expanded in scope. Staffed today by two full-time clinical psychologists, Florida Hospital PSS provides a range of preventive and therapeutic services for staff physicians, including individual and family counseling, seminars, retreats, coaching and training. In addition, PSS has been established in other markets within Adventist Health System, including four hospitals in Chicago and one in Kansas City.
PSS is a prime example of the principle of "doing good and doing well," providing a worthwhile benefit to both physicians and the hospitals in which they work. Privacy is carefully guarded, but anonymous feedback describes marriages restored, careers salvaged and personal and professional relationships enriched. It only seems logical that patient care and hospital staff relations have been positively impacted as well.
It is difficult to calculate a precise cost-benefit ratio for PSS services. However, we estimate that the cost to a health care institution of replacing a full-time physician who leaves practice or moves away approximates $250,000. At this rate, the recovery and retention of only two or three physicians who might otherwise have been lost to the practice of medicine more than covers the annual PSS budget.
Symptoms and signs of burnout include marital and family stress, substance abuse, auto accidents, health issues, depression and suicidal ideation. Inevitably, physician burnout surfaces in the workplace, compromising relationships with patients and staff and endangering the quality and safety of care. Often unaware of their own symptoms and sometimes insensitive to the impact on others, physicians are prone to stoicism and denial, carrying on with routine responsibilities until the personal burden is overwhelming, or maladaptive behavior can no longer be ignored.
The Maslach Burnout Inventory is a well-respected and widely used tool to assess professional burnout. It employs a series of questions designed to address three indicators: depersonalization (impersonal attitude toward patients and others), personal accomplishment (self-perception of influence and effectiveness) and emotional exhaustion (feelings of strain and fatigue).
AHS conducted a physician survey in 2011, incorporating the Maslach Burnout Inventory. The survey was mailed to a sample of about 1,500 physicians drawn at random from the American Medical Association database. Based on the 250 responses, survey results revealed that 25 percent of respondents were, by their own admission, at high risk of depersonalization. Almost a third admitted that they would not choose a medical career if they had a chance to do it over. And more than 40 percent of responding physicians assessed themselves as at high risk of emotional exhaustion.
There is growing interest in physician well-being around the country and, more particularly, within faith-based hospitals and systems. Beginning in 2010, Malcolm Herring, MD, of St. Vincent's Hospital in Indianapolis, Dianne McCallister, MD, then of Centura Health, Englewood, Colo., Brian Yanofchick, then director of mission integration for the Catholic Health Association, St. Louis, and I, representing AHS, began meeting together to create a vision for a broad, collaborative effort, extending beyond AHS, to address physician well-being.
Today, the Coalition for Physician Well-Being, a tax-exempt association, is composed of some 40 individuals representing more than 20 institutions, including several large Catholic hospitals and systems, along with AHS and Loma Linda University in California. We are committed to working together to help physicians experience greater life satisfaction and professional fulfillment.
The coalition sponsors hour-long, monthly teleconference/webinars covering an array of topics pertinent to understanding physician well-being. Topics include depression and burnout, physician alignment and engagement, spiritual formation and values development. Presentations are archived for retrieval as desired. The annual coalition meeting offers educational, networking and planning opportunities. Coalition leaders and members are available to interested organizations for consulting and coaching. The ultimate goal is to help physicians in achieving balanced lives, purposeful practices and meaningful relationships.
INCLUDE FAMILIES, COLLEAGUES
The task of engaging physicians and promoting physician well-being is critically dependent upon building healthy relationships. Without attempting to narrowly prioritize the relationships of highest importance to physicians, the top three arguably include those with spouses and families, with colleagues and with patients. Successful initiatives will take all three into account, not just conceptually, but logistically, in terms of scheduling programs around on-call and family responsibilities and planning events or activities that include families and colleagues.
Hospitals within Adventist Health System have sponsored a variety of programs designed to foster communication and build relationships, from picnics to art shows, physician concerts, health screenings and prayer breakfasts. One of the more successful and enduring events that has gained wide acceptance in AHS hospitals is known as "Finding Meaning in Medicine."
A small-group activity organized and hosted by physicians for the participation and benefit of physicians, "Finding Meaning in Medicine" was created by Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco. It consists of facilitated discussion of chosen topics reflecting what Remen refers to as "remembering the heart of medicine." Often in association with a meal in a relaxed setting, physicians are afforded an opportunity to share their own
experiences and stories on a selected theme. Participating physicians, with rare exception, say "Finding Meaning in Medicine" provides a rich and fulfilling collegial experience.
AHS also sponsors an annual conference designed to inspire and equip physician leaders to promote physician well-being. The two-day Conference on Physician Well-Being, now in its ninth year, brings together about 90 physicians and 40 senior executives from throughout the company for two days of motivation and education in a collegial setting. Consisting of plenary sessions, smaller breakouts and table discussion, the conference is intended to be practical, providing readily applicable programs, tools and resources for local implementation. Topics and issues addressed over the years have included communication and collegiality, purpose and meaning, margin and balance, marriage and family, spirituality and service, as well as AHS mission, vision and values.
Physician response to the conference has been gratifying. Here are typical responses to the standard conference survey:
- "Administration looking out for physician well-being was eye-opening"
- "Very refreshing … focused on emotional well-being and patient care"
- "New insights to use in reflecting on my own personal and professional situation"
- "It's rare to hear, 'I care about you as a person.' That's the message I heard"
- "The highlight was experiencing physicians bonding through candid discussion, hearing each other and being heard"
At AHS, we've been pursuing our physician well-being initiative for over a decade now. We conduct an annual, company-wide, physician engagement survey, and several questions have recently been added to more directly address issues of physician alignment and personal relationship with the hospital. We think areas of opportunity for the physician well-being program include strengthening physician orientation, leadership training and values-oriented physician recognition. We also are exploring ways to broaden the AHS emphasis on well-being to embrace a broader constituency within the hospital, including nurses, administrators and other staff.
Establishing a physician well-being program in a hospital requires physician leadership combined with administrative support. But it does not require that every member of the medical staff participate. According to quality pioneer W. Edwards Deming, "If you want to change the culture of an organization, you don't have to get everybody … you have to get the square root of N [the total number of people]. It will take on a life of its own and drive itself ahead." This implies that in a medium-sized hospital with an active medical staff of perhaps 400 doctors, it will take a group of 20 or so who are committed to the well-being of their colleagues to make a positive difference in the lives of their fellow physicians, and potentially, in the culture of the medical staff at large.
We believe that the fundamental mission of faith-based hospitals provides both a spiritual mandate and a cultural advantage for pursuing this work. We engage in this effort with the intent of extending the healing ministry of Jesus Christ to physicians, and through them, to our patients and staff.
TED HAMILTON is a family physician and vice president, medical mission, for Adventist Health System, a 44-hospital, faith-based health care system headquartered in Orlando, Fla.
- Eva Schernhammer, "Taking Their Own Lives — The High Rate of Physician Suicide," New England Journal of Medicine 352, no. 24 (June 16, 2005): 2473-76.
- Tait 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 (2012): 1377-85.
- Herdley Paolini et al., "Antidotes to Burnout: Fostering Physician Resiliency, Well-Being, and Holistic Development," Medscape Psychiatry, April 19, 2013; www.medscape.com/viewarticle/782514.
Coalition for Physician Well-Being, www.forphysicianwellbeing.org.
Finding Meaning in Medicine, www.theheartofmedicine.org.
Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.