Healthcare: Healing the Healers
Long hours, heavy workloads, high stress. How do doctors avoid burnout? Increasingly, with practices such as mindfulness and meditation
Many times during his 33-year career, Dr. Lo Fu Tan felt burned out and depressed. He had bad thoughts. He knew that his career and his family — and his patients — depended on him performing well. But the empathy, compassion, patience, and other qualities he’s always strived to personify sometimes evaporated. In those moments when he felt like he was on his last nerve, he would take it out on colleagues, staff — even patients.
“When you are burnt out or frustrated with that patient who is perhaps in your mind challenging what you are telling them or what you’re offering them, you become short with them,” says Tan, an urgent care and telemedicine provider with Southwest Medical. “You roll your eyes. You shorten the visit. You do all these things that you shouldn’t be doing, because it really doesn’t help the relationship with the patient.”
To help keep his mood upbeat, Tan has practiced meditation for many years. In fact, he hasn’t missed a morning session in the two-and-a-half years since going on a retreat with David Ji, who was Dr. Deepak Chopra’s lead educator for 10 years. Each day, Tan gets out of bed, makes coffee, showers, has breakfast, and then sits on a sofa chair in the dark for 30 minutes.
“The goal is to stay still and silent with hopes of hitting that sweet spot in which your mind stops the incessant thoughts that come to us,” Tan says. “When this happens, you might see colors like green, blue, purple.”
He aims to meditate twice a day. His morning routine at home is consistent, but trying to find the other half-hour a day is more challenging. Sometimes a session is just a 16-second mini-meditation. Still, even that helps him get “regrounded, reset, refocused, recharged, and get rid of bad stuff I’ve been collecting through the day.” He says, “When I’m in a better frame of mind, when I’m a happier guy and positive, then I can see that negative stuff going on around me much more clearly.” “That awareness is important and comes in part because of meditation. It gives you the opportunity to take a break … and get some silent time and stillness. The goal is to give your brain a bit of wakeful rest.”
Meditation is a focal point of Southwest Medical’s Moment Health, a mindfulness program introduced last year, an effort designed to help physicians and other health care providers renew their energy and enhance their performance. One of the program’s goals: reduce burnout among physicians. Tan was meditating regularly long before the program began, but he says it reassured him that he wasn’t “way out there” in thinking meditation was an important tool to avoid burnout. It turns out he was ahead of the curve.
Feel the Burnout
Popular television shows through the years such as M*A*S*H, St. Elsewhere, ER, Scrubs, House, and Grey’s Anatomy punctured the image of the tireless, infallible doctor. Doctors are still often glamorized, but unlike how they were portrayed in earlier TV classics such as Dr. Kildare, Ben Casey, and Marcus Welby, M.D., their flaws are more commonly dramatized, their personal lives explored more intensely, their anxieties and vulnerabilities more readily acknowledged.
Still, it may surprise some that widespread burnout in the health care industry has been a concern for more than a decade. Defined by the American Medical Association as “a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement, and a lack of empathy for patients,” burnout is even a metric that health care organizations track and monitor. For the first time since 2011, the physician burnout rate has dipped below 50 percent among doctors in the U.S., according to a new triennial study by the AMA, the Mayo Clinic, and the Stanford University School of Medicine. Almost 44 percent of U.S. physicians exhibited at least one symptom of burnout in 2017, compared with 54.4 percent in 2014 and 45.5 percent in 2011.
And the syndrome has a hefty price tag: Doctor burnout costs the U.S. health care system $4.6 billion a year in physician turnover and reduced clinical hours, according to a study published in the Annals of Internal Medicine in May. Factor in recruiting, onboarding, impact on those covering extra shifts, and loss of revenue or opportunity cost, the cost of replacing a doctor in an organization can be exorbitant. Patients suffer, too. Doctors who leave medicine midcareer cause patients to start over again with a new doctor. Other physicians who cut back their hours — especially in communities with an acute shortage such as Southern Nevada — make it more difficult for patients to obtain timely appointments. And a research review in the British Medical Journal in 2017 concluded that “there is moderate evidence that burnout is associated with safety-related quality of care.” It’s not hard to imagine tired, distracted, and exasperated doctors exhibiting impaired memory, lack of attention, and poor decision-making. Unnecessary testing, misprescribing medications, and errors in surgery are among the many serious ways patients’ well-being can be affected.
“The tide has not yet turned on the physician burnout crisis,” says Dr. Barbara L. McAneny, AMA president. “Despite improvements in the last three years, burnout levels remain much higher among physicians than other U.S. workers, a gap inflamed as the bureaucracy of modern medicine interferes with patient care and inflicts a toll on the well-being of physicians.”
The stakes involve more than improving patient outcomes and reducing doctor turnover. More alarming is the estimate that one doctor commits suicide in the U.S. every day — the highest suicide rate of any profession, according to findings presented at the American Psychiatric Association’s 2018 annual meeting. The number of doctor suicides — 28 to 40 per 100,000 — is more than twice that of the general population.
The study also showed that some of the most common diagnoses for doctors are mood disorders, alcoholism, and substance abuse.
Symptoms of burnout, applicable to people in other professions, are most disconcerting as patients await trained medical care in an exam room, an ER, or surgical suite. In a hospital, the stakes are higher and the causes of stress are stronger.
Doctors’ typical stressors, according to Dr. Dike Drummond, a Mayo-trained family practice physician and the founder and CEO of thehappymd.com: having a high level of responsibility and little control over the outcome; encounters with sick, scared, or hurting people with accompanying emotional needs; lack of work-life balance; leadership roles for which they were not trained; the sense that they are the bottleneck in providing health care; isolation behind the exam room’s closed door; confusing financial incentives; a hostile legal environment; and documentation requirements.
The doctor burnout dilemma calls for a broader strategy beyond self-awareness and meditation, including building out a proper staff to reduce the stress load on doctors in the first place. Health care organizations are realizing they must find ways to enable doctors to spend more of their time doing what they were trained for — instead of incessant management tasks and cumbersome electronic medical records. It’s a topic that seems to be gaining traction in hospitals and health care organizations, says Dr. Dylan Wint, a neurologist with the Cleveland Clinic Lou Ruvo Center for Brain Health.
“Burnout is something the larger Cleveland Clinic is concerned about and talks about a fair amount,” Wint says. “It seems to be a combination of increasing workload, but also an increasing proportion of the work that seems to be not medicine, per se, but various administrative tasks.” Employing more scribes for note-taking in exam rooms and refining software for visit documentation to customize for doctors’ specialties are among the practical efforts to make things more efficient, Wint says.
Dr. Jerry Reeves, medical director at Comagine Health, organized a Clark County Medical Society continuing medical education event in October to address physician burnout. The course, attended by about three dozen doctors, included presentations on tools and resources to identify and address burnout. They include self-assessment tools, and counseling and support services; adjusting schedules and staff to delegate tasks that don’t require clinical expertise and experience; building a culture of joy in the workplace; re-energizing the doctor-patient relationship; and telemedicine solutions.
“A lot of the onerous burdens of day-to-day practice has to do with wasted time and energies with moving patients from home to parking lot to office to exam room to out-processing,” Reeves says. “What the patient really may need are answers to questions that could just as easily be done through an e-visit or a telemedicine visit.”
Meditation, Mindfulness, and More
Conceived by Optum and implemented by Southwest Medical, monthly Moment Health mindfulness presentations are web-based and an hour long. Employees are encouraged to log on to watch during the workday. Topics have included eating mindfully during the workday; gratitude in the workplace; problem-solving with mindfulness; mindfulness, trauma, and loss; and enhancing workplace effectiveness. (Mindfulness is defined as a mental state achieved by focusing one’s awareness on the present while calmly acknowledging and accepting one’s feelings, thoughts, and physical sensations, used as a therapeutic technique, according to an Optum spokesman.)
And what’s good for doctors is good for patients, says Dr. John Rhodes, senior medical director of primary care delivery for Southwest Medical’s Mountain West Region. In addition to the local shortage of doctors and the national urgency to reduce doctors’ rates of divorce, substance abuse, and suicide, Rhodes cites the Institute for Healthcare Improvement’s Triple Aim framework — improve the patient experience, improve the health of populations, and reduce per capita costs. Adding provider satisfaction to the framework makes it a Quadruple Aim, Rhodes says.
“From a leadership standpoint, we’re willing to invest time and resources back to our providers and give them another option toward their overall physical spiritual and emotional health. That’s appreciated by many of our providers,” Rhodes says.
Chief among them is Tan, the meditation proponent spreading the mindfulness message to his Southwest Medical colleagues, whose mantra is “To Be Here Now.”
“That can be a challenge at times,” Tan says. “Adding this mindfulness program at the worksite gives us an opportunity to really be here now. It is about trying to improve our performance and be grounded and be focused on the present versus worrying about something that’s going to happen tomorrow or some mess-up that occurred the day before.”
The sessions are recorded so they can be accessed at any time. A “respite room” for doctors at Southwest Medical’s Oakey Health Center, stocked with art and comfortable furnishings, is a dedicated space for retreat, meditation, or simply decompression. Southwest Medical is adding more such rooms in its facilities.
Jennifer Bergdoll, vice president of human capital for Optum’s Mountain West Region, who was instrumental in the launch of the Moment Health program, says she was looking for ways to take care of the providers.
“We’re trying to be proactive in providing benefits to help our clinician workforce manage the demand in different ways. We want to be strategic and plan ahead. We know that the shortage isn’t going to change in the short term: What are the things we can do to help our providers manage in a busy environment?”
Participation has varied from 25 to 50 percent of the 3,000 employees to whom the program is available, Bergdoll says. Southwest Medical will continue to monitor participation and satisfaction rates and devise ways to enhance the program, she says.
Attention to the mental and emotional wellness of health care providers signals a cultural and generational shift as well. Realizing that doctors are only human, the UNLV School of Medicine is integrating wellness and well-being into the curriculum for future doctors.
RX TO RELAX
Anne Weisman, UNLV School of Medicine’s director of wellness and integrative medicine, encourages medical students to use relaxation techniques to avoid burnout.
“We’ve brought meditation, yoga, tai chi, therapy dogs, and a nutritional component as partners with Wynn Las Vegas,” says Anne Weisman, the school’s director of wellness and integrative medicine. “We’ve exposed our students to quite a few relaxation and wellness techniques while they’re beginning medical school so that this becomes part of their practice.”
Weisman works with students to develop plans so that they’re taking care of themselves. “We’ve chosen to do it pro-actively as a new school. This is part of our culture, this is who we are, this is what we’re doing. So we’re working with the medical students, we’re working with the residents, we’re working with faculty, the staff — it’s really trying to embed a culture of wellness and well-being into our School of Medicine from the get-go.”
The emphasis on overall wellness applies not just to future doctors, but to future patients as well. For instance, in integrative medicine, students are taught techniques outside traditional Western medicine — such as the use of essential oils, hypnotherapy, massage therapy, and acupuncture — to get a comprehensive view of their health and their patients’ health, Weisman says.
“The integrative medicine curriculum is throughout their coursework. The wellness stuff I’ve kept as optional, because I don’t want this to be something that causes additional stress,” Weisman says. Chair massage and pet therapists are the most popular, and she is working to refine the timing of the wellness opportunities around students’ class and testing schedules.
Wint, who has been practicing for more than two decades, says he doesn’t remember self-care as a common topic of discussion in medical school, residency, or fellowships back in his day. “It was kind of the opposite,” Wint says. “You were a bit soft or needy or a variety of not-complimentary terms if you did express a need to take care of yourself or show a vulnerability.”
Weisman, however, sees a generational change in medical students’ expectations. “Unlike their predecessors, they are unwilling to live this way. What’s great about this group of younger people is a real shift — we can do better in moving that needle. … It’s shifting gently and kindly. Maybe the way that (doctors) were trained wasn’t the most humane and appropriate way.”
When she got into the field, Weisman says she was struck by how little emotional intelligence was honored or taught. “How do you feel when you’ve just delivered a terminal disease diagnosis? How do you feel when you’ve had great outcomes, poor outcomes, or just the day-to-day emotions that come with taking care of people?”
“Adding this mindfulness program at the worksite gives us an opportunity to really be here now,” says Dr. Tan. “It is about trying to improve our performance and be grounded and be focused on the present.”
In her lectures, Weisman says she emphasizes the importance of doctors taking the time to prepare mentally, physically, emotionally, and spiritually before each encounter with a patient. “We can feel that and sense that from each other,” she says. “I would like our students and our doctors to be really clear as they’re working from patient to patient so that they’re able to be present and compassionate.”
‘Allow Me to Be Human’
But raising awareness about and building programs for doctor wellness is less a revolution than an evolution. One big hurdle is what Rhodes calls the Lone Ranger approach: reluctance among doctors to get help for themselves. Reasons include the ideal of putting patients first, time constraints, privacy issues, the prevalence of highly driven personalities who don’t easily admit weakness, and concerns about divulging substance abuse or mental health issues affecting their licensure.
“If you ask a fair number of my colleagues and myself who’s our primary care doctor, we will say ‘nobody’ or ‘ourselves.’” Wint says. “’When’s the last time you saw a doctor?’ Often (the answer) will be ‘a while.’ This is particularly true for those of us who don’t have any known medical conditions. When we do know we have something going on, we attend to it. But that primary care aspect might tend to be missed by a lot of us, if my nearby colleagues are examples of the general population.”
Tan, who is senior medical director of digital health for Southwest Medical’s Mountain West Region, believes the reluctance stems from how doctors have been trained and society’s expectations.
“One of things that our leadership in our organization has been working hard on in the last couple of years is to try to get away from that mythical professional standard and allow my colleagues and me to be human,” Tan says. “We have personal and family needs. If we are not healthy mentally and physically, we’re not going to be able to provide great care to our patients.”
The art of getting away
Physically and mentally getting away and powering down cellphones and laptops are important techniques to avoid burnout — but they’re also the ones doctors frequently find more difficult to implement.
Tan says he loves to explore natural attractions such as the Duck Creek area in Southern Utah or kayak down the lower Colorado.
“It’s still sometimes hard to turn off the work thing, but it really does help to do that,” Tan says. “It’s not just about meditation; there are so many other things that are important. … We get time off. It’s on me. I need to do a better job at turning it off. Otherwise, you could be at it 365 days a year. It’s a work in progress. Some do better than others, and I’m doing better than I used to.”
For Wint, the idea of a vacation of any length “feels impossible sometimes.” It’s a problem not unique to doctors, but one perhaps packing a greater degree of pressure than most other professions because someone’s life is at stake.
“As we’re sitting here, I got a text from a patient’s wife — I don’t even know how she got my cellphone number — and I don’t feel like I can just ignore it,” Wint says. “Is this woman texting me because her husband just got admitted to an ER or is it because I had an MRI scan two days ago that I’m scheduled to talk to them about (next week) but she just can’t wait? I can’t tell. There’s always this nagging fear that if you do turn off, someone’s going to be hurt by it.”
Finding another doctor to cover so nothing will go wrong simply because a problem went ignored for a few days is a challenge, Wint says.
“That means increasing our level of collegiality, increasing our level of vulnerability, and being able to say to a colleague, ‘Listen, I am just burnt out today. I need to take tomorrow off. Can you cover for me?’ That’s something that we are not that likely to say, but we ought to be doing so.”