PODCAST: Burnout and Practicing Today’s Medicine

Lorna Lynn: Hi I’m Lorna Lynn, an internist and the Vice President of Medical Education Research at the American Board of Internal Medicine. You might know us [as] ABIM, I’m here today with Drs. Ruth Kleinpell, Laura Evans and Bruno DiGiovine from ABIM’s Critical Care Medicine Board, welcome to you all. As you know, we’re here today to discuss an issue that is getting more and more attention: physician burnout. We know that doctors shoulder many responsibilities and seemingly excessive workloads. ABIM cares a lot about this topic and is actively working with the physician community to streamline and simplify our own processes and programs. In the next half hour or so, we’ll explore how we can support each other and find solutions to help doctors better manage the demands of practicing today’s medicine. But before we start, I’d like to go around the table and have each of you tell our listeners who you are and what your day job is. Laura, let’s start with you.

Laura Evans: Hi. I’m Laura Evans. I’m a Pulmonary Critical Care Trained Physician. My day job is I work at New York University at Bellevue Hospital, and I do a mix of clinical care. I spend half my time doing clinical care in the ICU and about half doing a mix of administrative work, patient safety, quality improvement, some implementation work and I help the U.S. health care system prepare for emerging infectious diseases.

Lorna Lynn: You sound busy.

Laura Evans: Yeah.

Lorna Lynn: Bruno, how about you?

Bruno DiGiovine: Yeah, my name is Bruno DiGiovine. I’m also a Pulmonary Critical Care Trained Physician; I’m the Division Head of Pulmonary Critical Care Medicine at Henry Ford Hospital where I work, administratively and clinically, in the ICU as well as in the outpatient pulmonary clinic.

Lorna Lynn: Ruth, not everyone knows that we have inter-professional members on all of our boards, and we’re so pleased to have you on the Critical Care Medicine Board particularly because you have special expertise in this area. So, could you introduce yourself and tell us a little about that?

Ruth Kleinpell: Well, thank you so much. My name is Ruth Kleinpell, and I am currently at Rush University Medical Centre in Chicago. I am an Acute Care Medical Nurse Practitioner; my background has been Surgical ICU. I am currently the Director of our Center for Clinical Research and Scholarship at Rush. I’m also a Professor of Nursing, and I teach in our nurse practitioner programs. I am the non-physician member on the Critical Medicine Board and I also wear dual hats in that I’m currently serving as the President of the Society of Critical Care Medicine(SCCM). So, this has been an area of interest at SCCM in terms of looking at measures to prevent and address burnout.

Lorna Lynn: So, why don’t we start by talking about just what burnout is and what some of the causes are? Ruth, maybe you can lead off.

Ruth Kleinpell: Yes, it’s something that is really defined as a constellation of symptoms. It was actually first identified as a diagnosis in the 1970s as really symptoms that appear in someone who does not have a history of psychological or psychiatric disorders. And, it really involves three areas of focus: it’s emotional exhaustion, depersonalization and then feelings of a decrease in some personal accomplishments. The literature actually highlights it as a phenomenon in all health professions but we see it in critical care, I think, due to the nature of the high stress work that we do as well.

Lorna Lynn: Bruno and Laura, does that ring any bells for you? What Ruth has described?

Bruno DiGiovine: Sure, I think we’ve all seen that in co-workers at different times. I recognize it a little bit in myself during my years of training as a resident where certainly there were a lot of those symptoms working long nights and days. It certainly is very troublesome when you see that. I think that it’s nice to begin to know that it’s not just me, that other people have similar symptoms.

Laura Evans: I think it does, sort of, resonate with us as critical care providers. I think it’s really interesting, the point that Ruth made, that it’s an issue that spans specialties. It certainly spans professions as well, and I think there’s some interesting work coming out of some the work that SCCM has been involved with in looking across the spectrum of critical care providers, nurses, other members of the ICU team and physicians as well. But, I think it does also span across disciplines of medicine as well. So, I think this is [not] an issue that is limited to critical care by any stretch of the imagination, but I do think the ICU may have some sort of factors that increase the likelihood of it, because the ICU is an especially physically and emotionally demanding area to work. We’re faced with gravely ill persons and often confront families and people at very vulnerable times during their lives as their loved one is very sick in the ICU. I think that adds to some potential for this exhaustion and depersonalization, even the sense of decrease of self efficacy around it.

Lorna Lynn: I think for a long time there’s been an attitude among physicians and other health care providers that we should just tough it out, we should just power through, or at least we should suffer in silence as we’re dealing with our own personal experiences of burnout. How do you think we can get better at recognizing the symptoms among our peers as well as in ourselves so that we can reach out and offer help?

Ruth Kleinpell: I think there’s more awareness now, and in the medical community, there’s certainly been research that has documented signs of burnout in nurses and physicians and, interestingly enough, there’s even a higher rate among pediatric ICU clinicians as well. We see a lot of movement efforts now in terms of not only recognizing burnout but in addressing it with interventions, both individual as well as organizational. So, I think it’s actually being proposed as a quality metric in some ways to be monitoring, you know, people’s sense of work health balance in the work environment as well.

Lorna Lynn: So what are some of those interventions? Maybe, we can touch on that, and maybe, we’ll start at individual level. What are some things that have been known to help?

Laura Evans: I think to tag onto that as to how do we recognize it, I think it’s really helpful if we construct an environment where we work – where we have a sense of looking after one another. The ICU is sort of the ultimate team-based environment, and I think we have to recognize that and look after the well-being of the team. Each and every team member has a responsibility to look after the well-being and the function of that team, not just the leadership role. There has to be a sort of an active engagement of everybody on that team to look after that and to be aware of some of the warning signs you see [in] your colleagues, or certainly yourself, perhaps be more callous than you like when you’re interacting with a patient or a family, or potentially having issues with just emotional or physical exhaustion. I think we have to actively participate, each and every one of us, in terms of trying to break that taboo about talking about it and being super heroes all the time and being able to admit our own limitations and say, “You know what, I need some help.”

Bruno DiGiovine: I think team building is one of the interventions that I think has been looked at to try to prevent burnout. I think some of the others have been around things like just mindfulness, taking some time to teach clinicians how to do a little bit of self-management, and self-repair around what they’re doing and how to find meaning in the important work we do. I think it’s interesting, because I think there are a lot of correlations when I think about this to what we’ve talked about for patient safety for a long time. I think we’ve grown up in an environment where an error was the fault of the clinician, and we’ve tried to learn that, actually, an error is typically a system problem and we need to fix it as a system. I think it’s the same thing we probably need to learn about burnout: that burnout is not a personal failing; it’s not that you’re weak; it’s not that you’re psychologically not prepared for the job; it is just part of the system of care that we’ve developed. I think [this] will lead to some organizational change, which I know that we’ll talk about as well.

Ruth Kleinpell: Yeah, you know, certainly things like mindfulness training have been beneficial but exercise, making sure of healthy diet, and adequate sleep and, you know, having hobbies and activities outside of work, trying to gain that piece of it as well. I mean those are things I think we need to be a bit more aware of how we’re feeling when we’re at the work setting. And, are there things we can do to have flexible scheduling or you know, things like that to help sort of mitigate? Can we change our roles if we just want to spend time on the rapid response team versus stepping in the ICU one day? What can we do to sort of just make work life a little bit healthier?

Laura Evans: One thing that I find that helped me was [that] as I took out more and more responsibility, [I] was trying to be very deliberate about approaching what my personal goals were and what my professional goals were and recognizing that conflict is intrinsic in some of those things when you’re ambitious and want to do a lot of things and want to be a very high- performing professional. There’s probably going to be conflict with what you want to do in your personal life and what you want to do in your professional life, and I think admitting that to myself was an important step, that these things do have conflict and recognizing it and trying to be deliberate about, “what are my professional goals; what are my personal goals; where might those conflicts arise; how will I try to deal with those?” and I think it’s been pretty well correlated that when there’s conflict in the work balance and the conflict wins, that leads to more burnout.

Lorna Lynn: It sounds like there are a lot of cultural changes that are needed. I’m thinking right now [how] I’m the mother of a pre-medical student, and I see the stress that she’s under even at that level and the pressure she feels from her pre-med adviser and from her peers, this enormous pressure to keep her GPA very high. I try to talk to her about the importance of self-care, and I’m hoping that the pipeline of students coming into the profession is changing in such a way that that is normal rather than the norm of always work harder, always try more; you’re weak if you say no to any request. Are you seeing any changes in the culture?

Ruth Kleinpell: I think there’s definitely more awareness, we know of facilities who have some psycho-social committees who have respite rooms, who have integrated, you know, yoga classes at work or have a health facility on site that they encourage employees to go to. So, you know when you look at organizationally decreasing your overall turn-over and increasing your retention and your staff’s satisfaction and engagement scores, I think it’s definitely a level of awareness in administration and health care that we didn’t have before.

Laura Evans: I think some fields are probably a little bit further ahead, and if you look at the hospice and palliative medicine field, I think they recognize—and it’s relatively newer field—they’ve recognized in some senses, [when] started as a specialty, that self-care is a really critical component of that, that you can’t provide the care you want to as a professional in that specialty without taking care of yourself. I think some of the other specialties are probably a little slower to come to that recognition, but I think it’s getting there that provider wellness is gaining attention across the board. Because of that link, the patient safety, medical errors and well-being—I think that those are all very related—hopefully organizations are starting to incorporate more systematic approaches into that, but I think we still have ways to go.

Bruno DiGiovine: I think we often see and we talk about generational differences, and I think we see that in our younger generation that they are more open about speaking about work-life balance. I think it is harder sometimes for my generation to accept that sort of very upfront statement of, “No, this is the limit to where I want,” you know, “This is what I want work to be like, and I want to work hard when I’m here, but I want to know that I have a balance.” I think that is something that is very different and something that we actually probably need to learn more from the younger generations so that they can help bring that into the healthcare workforce.

Lorna Lynn: So I’d like to ask you all some personal questions. Do you have a time that you remember where you were ever burned out or close to burnout, and would you be willing to share something about that and any tips as to how you helped yourself get through that and what might be helpful to others?

Bruno DiGiovine: I can certainly speak to a time when I felt burned out. I’m not sure I know how I got past it, but I do vividly remember being on call overnight as an internal [medicine] resident and envying patients who were in their beds, because they got to be in a bed, and I was working. Obviously, you can’t be empathetic to the problems of the patient when you feel that way. I think what was hard for me was that I didn’t have a word for it, and I think I didn’t recognize it, honestly, until I was far enough away and not so sleep-deprived that I could look back at that and go back to that and go, “God, I was really not in a good place then.” I wish I could tell you I know how I got past it other than that time passed and my sleep cycles and my work-life balance changed a little bit, but I didn’t know what burnout was then. I didn’t know how to approach it, but that certainly has always been a vivid memory for me of what can happen when you’re feeling that stressed.

Lorna Lynn: And hopefully some of the changes about sleep will help with that?

Bruno DiGiovine: Sure.

Lorna Lynn: Ruth or Laura, anything you could share?

Laura Evans: I think the hardest period of time for me, professionally to-date, was probably a few years after I finished fellowship training, and I was a junior attending, doing mostly ICU time. And again, sort of like Bruno, I didn’t have a clear word for it, but it was actually called to my attention by astute colleagues who said, “You know what, you’ve changed. You’re different than you were a year or two ago as a provider. You’re not as present, and you’re not as engaged as you were, and you seem toxic.” And it took them bringing it to my attention and I went, “You’re absolutely right. I am toxic.” And you know, the approach of how I fixed it, I think there wasn’t a major sea change intervention; I kind of stepped back and reflected a little bit. [I] took a couple of days off—which  really helped—and made a sort of deliberate choice of, “OK, I’m going to be more cognizant about what frustrations I can let go,” because I think we tend to be a little bit of perfectionists, and it’s so when things are wrong and you can’t fix them, at least I tend to internalize those a lot and have trouble letting them go. So, I became much more deliberate about it. There are certain things that I’m going to be able to fix. Whether its things about the system or things about colleagues or things about the environment, there are some things that I can’t fix and I just need to be able to let that go and not take that home with me. Even just that conscious choice to recognize that there are things that are outside of my control, it was very useful to me. I think that things that we can do that improve our sense of control over our work environment help a lot with decreasing burnout, but also then being able to step back and say that there are certain things that we’re not going to be able to control, and you just have to take a deep breath and move on.

Ruth Kleinpell: Well, I can say I certainly have been impacted by the stress of the ICU. I used to work night shifts for many years when I was in graduate school. You know, it really is the altered sleep cycles that help. So, I switched to the evening shift. At that time, we had eight-hour shifts. I worked 3-11 and I think that helped a lot. So, and that’s actually one of the things that’s recommended is taking vacations, taking respite times and changing your schedule.

Lorna Lynn: I’ve been [struck], from what I see about critical medical care—being married to a critical care physician and having spent some time in my training in the ICU, of course—by how closely the nurses and physicians and respiratory therapists and others all work together, but you’re also facing life and death situations, sometimes on a daily basis or even an hourly basis. Do you think the teamwork helps, but the acuity makes the situation more challenging? Are those some of the issues that come into play with burnout in a critical care setting?

Bruno DiGiovine: I think the acuity obviously plays a role. Although as I think about what is stressful in the ICU, it’s that the team work is that sort of double-edged sword. I mean I think we love teamwork when it goes well, but again feeling and being a group of practitioners—whether nurses, physicians, respiratory therapists—we all feel this high degree of some perfectionism. And if I can’t get something done because the nurse and I aren’t working together well, that really is what makes you frustrated.  I’m not sure it’s same; I mean, I think that a lot of what I see around the research, around the burnout in ICU, I think a lot of it revolves around often nurses who don’t understand why that sort of direction of care seems to be incongruent with what they think maybe is more reasonable or more feasible or… I think it’s that lack of-we’re not taught how to be good team members. We’re not ever taught how to work together well. So that if you and I are on ICU together and things aren’t going well, we have the tools to fix that and it’s something that I think leads to the burnout. Certainly, the fact that people are dying makes it hard, but I think it is the close interdependence. We cannot run the ICU without the teamwork and sometimes we just don’t know how to do it well.

Laura Evans: Yeah, I think it’s less the acuity of the patients themselves that causes sort of level of provider distress, and more when there’s a mismatch between what level of care is being provided and what the treating team sort of feels like is appropriate given the clinical circumstances. So, I think providers get very distressed when they are perceiving that the care that they’re providing is non-beneficial. So, if a patient is inevitably dying, and we’re still doing aggressive, invasive, potentially painful things that cause suffering with little perceived benefit, I think that contributes a lot to the sense of burnout and distress, moral distress amongst providers. I think recognizing that is really important, because there’s often times we can’t fix that, but we can recognize it. We can talk through what issues we’re having with it as a group and as a team, because different members of the team may be in different places along that continuum. I think recognizing those differences and being upfront about what we’re experiencing can be very helpful. So, we’ve actually instituted sort of inter-disciplinary conversations about difficult cases. We don’t have them on a clear schedule—they’re kind of on an adhoc basis—but we’ll get folks involved in the same room. We’ll often actually have one of our HUD care team come and sort of, you know, moderate a discussion amongst us about what the experiences are and it will at least sort of clear the air.

Ruth Kleinpell: You know, the critical care society collaborated with the four national critical care groups in the United States—which are the American Thoracic Society, CHEST or the American College of Chest Physicians, the American Association of Critical Care Nurses and the Society for Critical Care Medicine—and published  a call to action last July that was published in all four of the major journals to really raise awareness about burnout mitigation as well as prevention measures, and the groups are continuing to work in this arena. We have applied for funding from NIOSH that we’re waiting to hear back from. But regardless if we receive funding or not, the four organizations have agreed to support in the national summit December 1^st of this year (2017) in Chicago, where we’re bringing together 60 experts in many different fields—psychology, sociology, mindfulness, stress reduction technique—to really help inform our communities about what steps we can take in terms of really making things more actionable. I think individual sites are doing some things, but I think we need have collective information about what is beneficial and then disseminate this to our stakeholders.

Laura Evans: I think that would be really useful as a bedside provider to help guide folks at the bedside what interventions they can take. I think that would be incredibly useful to the field.

Lorna Lynn: I know that the National Academy of Medicine has this on its radar as an important issue as well and is looking at research that goes beyond cross-sectional, single-institution studies to try to learn what is effective in a variety of settings and what is sustainable as in effort overtime. So, it looks like there are some good things on the horizon to address this issue. Ruth—I know you touched on this a little bit when you mentioned provider turn-over—can you expand on how burnout relates to that and why we should care?

Ruth Kleinpell: Right. Well definitely if the work environment is not changed to a positive environment, you will see people that would leave—and whether they leave critical care to another healthcare area or whether they leave healthcare in general and go to another profession—we certainly don’t want to see that, because we know our clinicians are dedicated and we want to retain them in critical care for their expertise. So, I think there’s more awareness from the hospital administrators level that they don’t want to see high turn-over rates, they want to see good engagement rates. So there’s more support for having such organizational measures to decrease stress and burnout, whether it’s to be supporting fun events or to be looking at yoga classes or these types of things.

Lorna Lynn: So it sounds like both individual and system-level changes that we need to be considering and putting some effort into. I worry that we sometimes put additional burden on the individual doctors and nurses to find a way of dealing with their own problems. And while you’ve mentioned some things that have helped you, it’s nice to hear about these system-level changes that could be coming around. So, other thoughts you’d like to share in this arena?

Bruno DiGiovine: I think one of the things Ruth just mentioned—some system-based interventions—I think there’s going to be other system-based interventions that really get to the structure of care we provide. Laura talked about not feeling like you can provide the care you want, so nursing staffing ratios will be an easy example. There, I can’t imagine that there is not a correlation between nursing staffing ratios and the feeling of burnout. So, I think it’s going to become important for all of us to advocate for really measuring burnout in our providers, because without that, it becomes hard to advocate to say, “No, this really isn’t a safe staffing ratio. This is leading to burnout.” If we can change the staffing ratio or change the idea that physicians shouldn’t be on call for 24 hours and coming in at three in the morning and then rounding the next day and doing things that many of our colleagues do in practice, then maybe that would be an impetus for change because that is going to cost money. You need to have that sort of ROI, what it’s going to do for turnover and how it’s going to improve other aspects of care when you’re trying to intervene on these things.

Laura Evans: Yeah, I would agree with that. I think the point that you made about systems-level intervention is very well taken, because simply telling providers to eat better and sleep more is not enough. People have too many competing priorities and that’s not enough of an intervention. We need systems-based and organizational support to, I think, really change the culture of how this works if we’re going to be really serious about addressing this.

Ruth Kleinpell: Well, even things like team-based training—making sure that we’re having, you know, respectful conversations, adequate communication team training—those things are so important as well.

Lorna Lynn: Well, I’m sure that we could continue talking about this for much longer, but as we wrap up, I want to thank you Ruth and Bruno and Laura for joining me today. We appreciate you taking the time to discuss this important issue, and we hope that this conversation can be useful to our colleagues. Of course this is just the beginning of an ongoing dialogue, and we look forward to more opportunities for discussions like this in the future. Thank you so much.

Ruth, Bruno and Laura: Thank you.