COMMENTARY

Physician Experts Tell How to Combat Burnout

Cheryl Pegus, MD; Ramon E. Jacobs-Shaw, MD, MPA; Gabriel A. Sara, MD  

Disclosures

September 29, 2017

Cheryl Pegus, MD: Hi. I'm Cheryl Pegus, cardiologist, president of Caluent, and clinical professor of medicine and population health at New York University (NYU) School of Medicine. Burnout is rampant, and it's having a significant impact on physicians and, in some cases, their patients. What exactly is burnout? It's been defined as emotional exhaustion, long-term irresolvable job stress, a sense of being overwhelmed, depersonalization, and a loss of a sense of personal accomplishment.

Medscape did a physician lifestyle report in 2017, and it showed that some of the leading causes of burnout include: too many bureaucratic tasks, too many hours at work, feeling like just a cog in the wheel, dealing with electronic medical records (EMRs), not earning enough money, insurance issues, difficult patients, and, of course, many other causes.

Who's feeling it the most? Overall, 51% of physicians report feeling burned out, although some specialists experience it more than others. The highest levels of burnout were reported among emergency physicians, obstetricians/gynecologists, family physicians, and internists. Note: This was a substantial rise from 2013, when the figure was only 40%. We've gone from 40% to 51%. Here to discuss this with us are Dr Gabriel Sara, an oncologist and the executive director of patient services at Mount Sinai Health System, and Dr Ramon Shaw, a hospitalist physician from NYU Langone Medical Center and the medical director of the Department of Care Management and Care Transitions at NYU Langone.

Gabriel A. Sara, MD: I am a medical oncologist. I have been in practice since 1987. About 10 years ago, I joined Roosevelt Hospital, which today is Mount Sinai West, and I'm the medical director of the Chemotherapy Suite.

Dr Pegus: Thank you. Dr Ramon?

Ramon E. Jacobs-Shaw, MD, MPA: I am a hospitalist, which means that I am a hospital medicine expert. I have now started my 12th year as that. Trained as both a pediatrician and as an adult physician, I help to teach the hospital trainees and medical students; and I'm also, as of earlier this year, the medical director for the Department of Care Management and Care Transition.

Dr Pegus: Dr Sara, you've started a really innovative program at Mount Sinai for physicians to help combat burnout. Can you tell us a little bit about that program? When did it start?

Dr Sara: Almost 15 years ago. One day I was rounding in the hospital, and one of our oncology fellows—a very nice guy, very low profile, doesn't talk much, doesn't share much—grabs me in the hallway and tells me, "Dr Sara, I'd like to talk to you." I really felt in his tone that he seemed to have something really hard to talk about.

He was feeling very disturbed. I felt that, and I stopped working. I said, "Let's go together." I took him to a room, we sat down, and I said, "What's going on?" He told me, "I'm treating a patient with acute leukemia who is exactly my age, and all the treatment failed, and she's dying. I feel horrible about it. I feel I failed." I sat down with him and coached him about how he can cope with this feeling. I could see how intense his pain was, and I also realized that nobody ever told him how you could cope with the feelings that he's going to have to deal with all of his life as an oncologist. As I was going back to my office, I said to myself, how was I so blind? This guy was in front of me, and he talked to me, I saw it. How many around me are feeling the same way? Nurses and doctors?

Dr Pegus: You host these sessions. How often do you host them and how did they start?

Dr Sara: I started it with once a month, which we kept doing because it's hard to find the time for people—that's one of the problems. It's hard to find the time to take care of your own feelings. We have once a month, from 8 AM to 9 AM, a breakfast meeting where 10-20 people come. There will be many more nurses than doctors because they are on the floor, but we have doctors and nurses. We also have music therapists, artists, a chaplain, a social worker, and they come, all together. We sit down, and then there is usually one or two who volunteer to share a story that was hard emotionally or beautiful emotionally but challenging.

They tell their story. We don't talk about medical issues at all, just emotion, how we cope with it, how our patients and colleagues cope with it, and we start discussing it. The discussion takes us to amazing places, where you feel there is a lot of healing and sharing that goes on. Since we've been doing it, I find that there is a totally different atmosphere on that floor. I do it on the oncology floor where we also have medical patients, but it has transformed the atmosphere, how people are coping with stress, and how people are dealing with sick patients, difficult people.

Dr Pegus: Ramon, you see a lot of medical students and a lot of residents. What are the types, signs, and symptoms that you see of burnout?

Dr Jacobs-Shaw: Sometimes the symptoms can be so hard to recognize. We work with folks who are working these intense hours with a lot of demands on their time. Recognizing that can sometimes be tricky. I think that physicians are sometimes the worst at recognizing that in their colleagues and in the trainees. I can observe quite a bit with my house staff and my medical students. Sometimes it really shows up quite simply as compassion fatigue. I look at how they are interacting with their patients or how depersonalized they may actually describe the patients and everything. I think that is the first thing that I tend to see in our trainees.

Dr Pegus: I think, when we talk about recognizing the signs and symptoms of people who are suffering with burnout, the question is: How do we approach them? How do we begin the conversation? Who has the responsibility in a hospital? I think you, as an attending, have taken a responsibility for those who are being trained. Who do we think has the responsibility in a health system to do this, and should we be proactively having these available for people to take advantage of?

Dr Jacobs-Shaw: First of all, we must recognize that it is a problem, and we need to do something. There were about eight to 10 CEOs who were the authors of this particular article in Health Affairs. They were really discussing how much of a crisis we're in with physician burnout but also recognizing that we, as the leaders within the institution, must realize that this is not only affecting the individual who is suffering burnout, but it's also affecting the organization and the repercussions that come from that. Also on a patient level, we know that physician burnout can affect the quality and safety of care that is delivered to patients. It must come from senior leadership.

Dr Pegus: People always recommend yoga and meditation to help with stress. Are there any suggestions, Gabriel?

Dr Sara: It's hard to give you a recipe that works for everybody. I'm sorry to tell you that I don't have the answer for this specific question right now, but I feel the fact that you're acknowledging to yourself that you have a stress issue will help you find a solution. Maybe talking to people who are working close to you may help you find something that works for you. Certainly, yoga and meditation are worth trying if you have the time. I would not just discount it.

Dr Pegus: You may not like meditation and yoga, but you may like knowing that you have a blocked-out time on your calendar. One of the things that's definitively recommended is combining your work calendar and your personal calendar and marking off some personal time to pursue something that allows you to destress.

What are current hourly cut-offs for medical students, interns, and residents; and are they fair? Do they contribute to burnout?

Dr Jacobs-Shaw: The work hour rules have been around for house staff probably since before my training. Before my training, 15 or more years ago, those hours did change. Do I think they are fair? I do, but they are on the national scale. I think it might be necessary to revise the number of hours people can work consecutively. We do know that there are more data since those work hours have come out showing how that has affected the overall level of safety and errors that happen within the hospital.

Dr Pegus: Dr Sara?

Dr Sara: I do have a comment on the number of hours. We are in a world where numbers matter for everything, and numbers are becoming everything. That's a shame. For the hours, we measure hours. In reality, it's not the hours we should measure; it's what we do in those hours. When I trained in the early '80s, we didn't have computers, and we didn't have all of this extra administrative stuff we have, which has not affected our patients' outcomes but has increased our workload. We would work some weeks 90 hours in a week, which today would seem absolutely inhumane, but we survived those hours. I'm not recommending that anyone does that. Obviously not.

Dr Jacobs-Shaw: I'm glad you're not.

Dr Sara: I think that those hours were hours we spent where we were doing something meaningful during all of those hours. Today, when you sit in front of your computer to catch up with all of the paperwork and all of the administrative stuff that takes your time, in my opinion, the burnout from these hours is more than the burnout when you are in action. You're thinking of a patient, you're helping somebody, you're doing something meaningful immediately for the patient.

Dr Pegus: I do think that as we look at how healthcare has changed, the real question is: Are we training people to now accommodate this new set of rules and how we practice medicine? Frankly, EMRs are not going away. The real issue is: How do we get comfortable, and how do we utilize tools and a team-based approach to care? Are more docs burned out today than before, or are docs more comfortable talking about it today than they were before?

Dr Sara: I think they are more burned out right now. People are talking about it. Obviously, people are going to come out and say it. I think that there are more burned out people than what we hear. Probably there's more than 51% because many people may not even realize that they're burned out. They're not going to say it, and some know it but then don't say it. I think the 51% probably is less than what the reality is.

Dr Jacobs-Shaw: There's maybe a stigma to it, where people don't actually feel they want to voice it.

Dr Sara: To admit it themselves.

Dr Jacobs-Shaw: That that is what they're feeling. Sometimes even with burnout, it can be hard to differentiate between burnout or even depressive symptoms or feeling depression. With some underlying mental health and behavioral health issues, it can be hard to tease that out. From 2011 to 2017, in the Medscape survey, more people are saying that they feel burnout. This is not just from a sampling of a few hundred people. These are over 10,000 people who are responding, all physicians, to this. We know it's a problem that in 6 years, more people are saying it's a problem.

Dr Pegus: We started talking a little bit about medical students and residents as they enter the field and what they're also experiencing and being able to deal with regarding the transitioning healthcare program. If you are on the floor, and you have medical students or residents or fellows who are working with you, do you actively go up and talk about these long hours and try to build a relationship? Are you saying, "We should have lunch sometime"? How are you building those mentoring relationships with the young trainees, and how are you doing it with your colleagues? I think that one of the things we need to consider is how we go back and do some of these things in our own institutions. I would love to hear how you're doing that.

Dr Jacobs-Shaw: Yes, I think that one thing we don't talk enough about when it comes to burnout is the role of mentorship and finding purpose in work. I think that when it comes to what we do, there is so much of that administrative burden that we do have to do. There are regular burdens that we have to comply with. At the same time, we still have to find that purpose in the work and what we do. Working with trainees and medical students is awfully rewarding.

I think that one thing we can do is to recognize the breadth of the work that we do but also realize how challenging and how difficult it is. From an inpatient perspective, we're dealing with the sickest of the sick folks. Nowadays, getting into the hospital is much more difficult than it used to be 5, 10, or even 20 years ago. When it comes to that, we have to recognize that it is hard. I think that when we vocalize that and we say what important work we're doing but what hard and challenging work it is, it opens up a dialogue for people to then say, "It is hard. It is challenging. Let's talk about how that makes me feel as a provider within this context of this current healthcare system."

Dr Pegus: That's a great point.

Dr Sara: I would like to add to these issues what I call passion and empowerment. Those medical students in general work very hard to become medical students. Most of them are dreaming that this is a beautiful profession. It's not an office job, where you sit behind your desk 9 to 5. You are here in a community. You are here because of a mission to make a difference for people who need you. You need to learn how to become that person. The students come in with those dreams, and then frequently the reality makes them lose them.

I want to nurture that; I want to make them realize that it is a passion to be a doctor. It's an amazing mission to be able to be a healer, and that's what your role is about. When you get them to feel it and live it with you in your experience with your patients, it is contagious and it's delicious, and they start to feel it.

I think the feeling of being someone who can make a difference around us because we learned something and we're doing it well can help us cope with all of the headaches of the administrative stuff, EMRs, etc, because they're not really our life.

Dr Pegus: I know we've talked about it, Ramon. This is one of the best fields and one of the best careers. Being able to manage and support each other through it, as I like to say, until you're pushing me out in my wheelchair. These are people's lives, but they're long relationships; you're dealing with different specialties. What can we do to take away the stigma of burnout?

Dr Sara: We can increase the awareness that it's a dangerous thing that we are all exposed to. No one is protected from burnout, number one. First of all, tell people, "Listen, there's nothing wrong with acknowledging it. Let's talk about it." I think that the most important thing is to push people to realize that they're not alone. Part of that passion is that I feel this way, but you feel this way too, and he feels this way too. We start feeling that we're not alone. You feel better just by knowing that, and then you must address it. You have to face it. We can't be wishy wash talking about it; we have to really sit down. We must put it on the table, talk about it, and see what we can do about it.

Dr Pegus: I think it speaks also to the culture of your work environment. Are you in a work environment where you feel comfortable with your colleagues? I think it's something people should always look at: How are we working together as a team? If I have an issue, am I comfortable going to my colleagues and saying, "Hey, I noticed this; can we talk about this?" What role can hospital administration play in reducing burnout? Ramon?

Dr Jacobs-Shaw: It is so important that we are attaching our names to this and saying that we need to do something at a national level. Also, at the same time, we want to do something, and we have pledged to do something within our own organization to help address this. What are some bullet points? How are we going to do this and really come up with strategies? I think that seeing it and hearing it from that most senior level is important, but at the same time, what are we doing at the local level? What are we doing at the individual level? On those units, on those floors, in the office, in the clinic, we need to have that discussion about how difficult it is. I have been accused of this as well; we must celebrate when the good things happen. We don't often do that.

Dr Sara: I think that this is so important in what you were mentioning, the big people are talking about it. Think about the kind of medicine we're dealing with today. We're constantly bombarded and besieged by surveys of patient satisfaction, which is important. Did anyone do a survey of the doctors, nurses, and housekeepers who work in the hospital? Are they satisfied? Are they happy?

If everybody was happy in their job, the productivity would be so much better, the burnout would go down, and they'd make more money in administration. I think there's not enough of that; it has to come from the top. You have to have programs that are geared to ask, "Are you happy, Ramon? How does it feel?" It has to be on an institution basis. We should have gyms in the hospital. You should have rewards if you go to the gym on a regular basis. You should have organized entertainment. I have a program for my patients that includes massage, music therapy, and art. We do it for the staff as well.

Dr Jacobs-Shaw: What the CEOs actually suggested in the article [in Health Affairs] was right on their dashboards on the length of stay and the readmission rates for the hospital. There's also the physician workforce satisfaction that's sitting right up there with those things. It makes it equivalent to those other aspects of how we run our hospital system.

Dr Pegus: For hospital administrators, it is taking the pulse of your employees and really finding out and putting in some of the solutions, as you've mentioned, and making sure there is access to a facility to work out or, if not, a membership discount that allows everyone from the physicians throughout to do it. You mentioned how you started your program at Mount Sinai with one fellow. What are some of the other symptoms that you see and hear about, Dr Sara?

Dr Sara: You look at people's eyes, and that shine that they had before is gone. You don't see the light they had when they started their training or their work. You see them, they never smile, they're constantly exhausted, they're constantly complaining about things. You don't feel that their day was rewarding. These are definitively signs of burnout developing, and we should really see that and recognize it. Despite all of the trouble we have, our work should be a passion and a job where we go with love and passion and feel all the time. That gives a lot of energy, by the way.

Dr Pegus: That's right.

Dr Sara: The opposite is happening when you're starting to have burnout.

Dr Pegus: Some other things we've said...

Dr Sara: That drive is gone.

Dr Pegus: ...not wanting to be at work, not feeling satisfied with the work that you're doing, not being interested in participating in any events that really help improve productivity at work. Does physician burnout affect patients and, if that happens, how?

Dr Jacobs-Shaw: What we know is that the quality of the care that is delivered to patients from people who self-identify as having burnout is less. Those people who experience burnout are more likely to have more safety events or errors in the care of a patient. This has been studied.

Dr Sara: Medicine is first about listening to your patient. Listening to your patient means connecting to your patient. It's almost a religious experience. If I completely give in to my burnout syndrome, you don't count much for me. I just want to survive my day. I want to get you out of the office as quickly as I can, so I'm not going to listen to you; I'm not going to give you the time to talk. You're not going to give me your symptoms well. I'm going to just do whatever looks good on paper, without realizing that I'm doing that. I just want to get done with my day. You're going to have a misdiagnosis, you're going to miss the symptoms, you're going to order the wrong test, and you're going to order the wrong dose. The effect on the patient's care...

Dr Pegus: ...is real.

Dr Sara: Yes, but patients feel it. I always tell my patients: "If you walked out of a doctor's office with a problem, even if we did not solve it for you, and you did not feel better than when you walked in, change doctors. That doctor has to make you feel that he cares about you, that he's going to work on your problem, and it should make you feel better than when you walked in. If you don't feel this way, change doctors."

Dr Pegus: Medscape has a number of resources on their website about how to address burnout. I would highly recommend to people that they look at that. As we mentioned, the survey that really started this discussion was completed by Medscape. The other thing is that the American Medical Association has a tool kit on addressing burnout, and so does the American [Academy] of Family [Physicians], and the American College of Physicians (ACP).

There are a number of different resources available. There are also a number of tools for measuring burnout. You can find them in any of these kits. They are available. If you are talking to a coach, which we know we have not talked about yet—we've talked about a mentor, but a mentor and a coach—if you find you are trying to figure out what are the next steps in my career, what are the things I should be doing, the administration and human resources department at a lot of your institutions actually have resources that allow you to address some of that. Are there other things that you would like to add, Dr Sara, Dr Jacobs-Shaw?

Dr Sara: I think that in a given institution, you will have some people who are more gifted at coaching and mentoring people. This is normal. I think the administration should recognize these people, and they could be in any specialty. It's just their personality. These people should be responsible for regular meetings. Sit down and say, "How was it this month?" I think we should be ahead of the game. When the doctors are burned out, it's sometimes so hard to bring them back. I think that we should be ahead of it and try not to get there by regularly having those kinds of meetings maybe once a month. We have a division but acknowledge who can run those meetings and then help people talk. It has to become something we can talk about easily, not something you put in the closet.

Dr Pegus: I think that the issues we have brought up today are taking the stigma away by acknowledging burnout at the administrative level and then with our colleagues.

Dr Jacobs-Shaw: I do not think at all that burnout affects one group or a personality type more than any other person. I think that it can affect any person, female or male, older physicians, younger physicians, fresh out of training or have been training for decades; burnout does not know a specific group and can affect any person.

Dr Pegus: Dr Sara, what do you think?

Dr Sara: I know that all of us are at risk. Nobody is protected. What I will say is that your experience in your previous life before becoming a doctor might give you a lot of resiliency. I find this a common situation. When people have had a tough life or went through difficult things that they survived, the burnout doesn't touch them that much.

Dr Pegus: How do you build resilience? Setting boundaries. Talking things out with others. A team approach to work and life. Having humor; I think you've seen a lot of that today from us. Taking some time away from work. A self-awareness and self-acceptance of who you are. I think resilience is a really important factor in burnout. We all experience burnout, we all have the potential to bounce back.

Dr Jacobs-Shaw: We were talking earlier about emails and that email connectedness as well. What I do for myself is that when it is vacation time, it is vacation time. I turn on my out-of-office message. I am not responding while I am away because I need that time to recharge. When I get back to the business of work and seeing patients, I want to feel like I'm refreshed and recharged for that.

Dr Sara: What I'm finding now is that if I don't check my work email while I'm away, just knock them off, when I come back, it's terrible.

Dr Jacobs-Shaw: A long list.

Dr Sara: Plus you might miss some important messages buried in the thousand messages that you have to go through. While I do send an out-of-office message, recently I've been saying, "People, please do not put me on any CC from that day to that day because I'm not going to look at your email." It cuts down the number of messages I get when I'm away. I'm going to do it every time from now on, even if it hurts people. I have to clean up my inbox so that when I come back, it's not horrible.

Dr Pegus: How do you reverse burnout once you're there?

Dr Jacobs-Shaw: Definitively one way is to find your passion. If you've lost your passion, recognize that you've lost that drive for that passion but also that life outside of the work environment is more important than life inside of that. It is essential to balance and recognize that you have loved ones outside of your work environment, and you must nurture and make sure that you keep those relationships safe and sound.

Dr Sara: If I'm going to help somebody who I feel is stuck in that box, I want to first try to let that person talk, talk enough to understand what the burnout factors are for them. For each person, there will be some factors that are more predominant than others. I want to identify what the problems are that got them to be feeling this way and then try to tackle them each one after the other. As Ramon said, I will try to remind them that they do have a passion; it's not gone. Just don't let it sleep. Bring it back.

Dr Jacobs-Shaw: Yes, find it again.

Dr Sara: That's so important, and that can be the most powerful tool: finding your passion. First let's see what happened and how we can make it better. Frequently, I find that when I do that with people, they wake up. I can see their eyes change, and they feel different. I check with them later on. It's like you can reset the clock. Burnout is not an irreversible thing, but we need to see it happening, find the causes, work on them, and get the passion back.

Dr Pegus: You can start by managing your calendars a little better, setting aside time for yourself and for your family. One of thing things I have learned, which I think as a woman sometimes is hard, is not to say yes to everything. There are some things that you can say no to and really try to manage that, saying it in a polite manner. If you need mental health treatment, seek it out. If you need a coach, seek it out. We all go through having stressful times that lead to burnout. Though technology has been introduced recently, and we talk more about pay for performance, a value-based program, physicians have been experiencing burnout for a long time. What we try to do to support ourselves and support each other is to talk about it, ask for help, and try to balance our family time with our work time.

I'd like to thank our two experienced experts who really shared great advice. Thank you, Dr Gabriel Sara and Dr Ramon Jacobs-Shaw.

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