COMMENTARY

'Hope' and 'Optimism' for Reducing Physician Burnout

An Interview With Stanford's Chief Wellness Officer

Interviewer: Robert A. Harrington, MD; Interviewee: Tait D. Shanafelt, MD

Disclosures

January 15, 2019

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, here on Medscape Cardiology and theheart.org.

We are going to talk about something both problematic and resonating within the cardiology community: physician and clinician wellness. The topic has gained a lot of lay press with the notion being that clinical care providers are at risk for things like depression, suicide, and burnout.[1] We hear about "resiliency" and "worrying about wellness."

All of this seems to be coming at a time when the demands of medical practice are increasing. There are demands with the electronic health record (EHR) and documentation. There are demands to generate revenue for health systems. There are demands to be accountable for delivering the highest quality of care, which is now measurable and reported back to a variety of oversight bodies, including the payers. All of this has created an environment where there is a great deal of stress in the cardiovascular community, so I thought it would be worthwhile to have a colleague from Stanford help us address some of these topics and get some conversation going in the community.

Tait D. Shanafelt, MD

I'm really pleased today to have my colleague from Stanford, Dr Tait Shanafelt, with us. Tait is the chief wellness officer for Stanford Medicine. He's also the Jeanie and Stew Ritchie Professor of Medicine here in the Stanford School of Medicine. Of note, he is a hematologist who has expertise and interest in the care of patients with chronic lymphocytic leukemia. Tait, thanks for joining us here today on Medscape Cardiology.

Tait D. Shanafelt, MD: Thanks for having me, Bob.

An Early Interest in Clinician Wellness

Harrington: Let's go back to the beginning. You were working as an R01-funded laboratory investigator in hematology at the Mayo Clinic and you got interested in the topic of clinician wellness. How did that happen?

Shanafelt: I first got interested back when I was a third-year resident at the University of Washington, almost 20 years ago now. I was preparing for a research block and my great mentor, Tony Back, was meeting with me to talk about what we wanted to work on. I shared with him that one of the things I was interested in was studying the experience of residency training.

Tony asked me a number of good questions, like mentors do, about what I was observing and what my hypothesis was. I shared with him that now that I was a senior resident leading teams, I was watching the plight of the interns and the way they would react to another admission, particularly late-night admissions (before work-hour limits), and so forth. In a sense, I was seeing that folks who went into this profession to care for patients were having reactions that were not in keeping with that altruism.

Tony and I did a small study[2] at the University of Washington that was one of the first to look at links between quality of care and patient outcomes. When we published, it became a real lighting rod study that got a lot of lay press and other coverage. I remember vividly riding on a shuttle bus between two hospitals as a hematology oncology fellow on consult service and hearing Paul Harvey on national radio discussing the study.

It was sort of this aha moment. Here was an unfunded study that had been done by a junior person and it was creating a new dialog and a new discussion and it helped me realize that we had known about some of this for a long time. Obviously, it's sort of The House of God material. And yet what was going to probably drive progress was research in the area like it does in all areas of our profession.

That led to a series of additional studies that we started at Mayo Clinic and then we started being asked by a number of national societies to lead studies on their behalf and begin to transition toward interventions and a system-level change.

Mapping Out Areas of Focus

Harrington: That was a great overview and it's important for our audience to hear. I want to stress something you said: this is not a new topic. I remember reading The House of God the summer before I started medical school and thinking, "Oh my God, this is clearly fiction." But then I got into the training experience—particularly as a resident when you truly have responsibility—and realized that the anecdotes and stories in The House of God actually were based on truthful observations.

What you did was different than just make observations, which is critical in terms of thinking about moving this area forward. You applied the scientific method. Your early work at Mayo and the research questions that you were asking about clinician wellness and how people observe their work, and how you were thinking about quantifying terms like resiliency and burnout, are how we at Stanford got to know you. Talk about that initial work and what you learned and how that sort of set the framework for what you call the "interventional studies" that were to come.

Shanafelt: Distress experienced in medicine is multifaceted. Burnout is one of the most common, but not the only, domain of professional distress physicians experience. For the first 5 or 6 years, all of the studies we did had two areas of focus. One was to look at the incidence of distress on physicians and when in the process of training, career, and practice these symptoms started to develop and their driving factors.

The second area of focus was almost always on the links to quality of care, effects on access, patient experience, and so forth, because we believed that this latter aspect was also what would drive change. We didn't just apply a scientific approach to understand the problems, its drivers, and personal implications for physicians, but also to learn what would drive hospital leaders, administrators, patients, and others to come to the table and think about this challenge we face and what we might do about it. What were the professional repercussions and how this was affecting the care we deliver?

That is how we started on that journey and engaging in the number of large professional societies. Over a decade ago, the American College of Surgeons was really the first large national college we engaged with; we did a series of studies with the college.[3,4] It was refreshing in the sense that surgeons don't like to just define problems, they like to fix them. That was also a helpful early step of really starting to think about defining driver dimensions that were actionable through the system lens.

Harrington: That is critical, that people see what is happening to them and their colleagues, or experience what is happening to them. I like your use of the word distress because distress then manifests itself in a variety of different ways, along a spectrum of severity.

But we do have to get to a point where we think about the impact. What does it mean for our patients? Ourselves? Our profession? If this is felt to be a natural consequence of being in a healing profession, perhaps through intervention we can begin to make things better.

Talk a little bit about the intervention piece and some of the observations you made, whether with the surgeons or other groups including your group at Mayo Clinic. What did you start learning that might work to help physicians?

What Drives Distress?

Shanafelt: As we studied the driver dimensions, there were a lot of different labels we could place on them and ways we could group them. We fundamentally organized them into seven areas[5]:

  • Workload and job demands;

  • Efficiency of the practice environment and available support;

  • Flexibility and control the physician has over their work;

  • Alignment of the values of the organization with its real purpose and strategy;

  • Meaning in work;

  • Work life integration; and

  • Collegiality and support.

I think we have always felt that a career in medicine involved a complex field and a heavy workload and was emotionally demanding. Yet, what are the things that have always seen us through? I have always viewed that the work itself was inherently noble and that our amazing dedicated, hardworking, and altruistic colleagues were committed to supporting each other in that work.

As we grouped things into these different driver dimensions, we would then start to think about which of these are the most actionable. The workload, for example, might not be the most actionable domain. Over the arc of the last decade, our productivity and what we are being asked to deliver has continued to increase. There are many reasons to expect that to persist: the shortage of physicians, many more Americans needing access to healthcare, and the increasing complexity of the care we provide.

But others were ripe opportunities: improving efficiency; creating flexibility; reengineering the environment to help physicians better connect with each other, giving voice and input on local challenges in their work unit so they could redesign the environment to help them take care of patients more effectively.

In that sense, we would try to identify one of these and develop, with input from various experts in that sphere, what we believed would be an intervention that could be refined and tested. Then we would ideally engage in a scientific approach. Many of these were true randomized interventions and others were sort of simple natural history experiments of looking at a pre-post [intervention] across a large organization.

Interventions

Harrington: Both from your science as well as your observations on the national scene, give the listener examples of interventions that you have seen have success, whether anecdotes you have heard about or ones that emerged from your randomized comparisons.

Shanafelt: One of the early studies[6] we designed and tested with two of my colleagues, Dr Colin West and Dr Lotte Dyrbye, at Mayo, was to focus on this sense of reconnecting physicians to each other to think about the meaningful and challenging elements of a career in medicine.

We enrolled a group of physicians and randomized them to have an extra hour every 2 weeks that we bought with a grant. We randomized how that hour was used. One group used the hour to catch up on work or get home earlier. The other group used the hour to meet with colleagues and to have a facilitated discussion around both positive things (eg, meaningful patient encounters in the last 2 weeks that reminded you why you went into this profession) and challenging elements of their career (eg, personal repercussions for your family because you pursued a career in medicine). The hope was that this would both restore community and reconnect physicians to some of the meaning in their work because many of the other characteristics in our current practice environment distract us from the really meaningful things that happen in our work day.

Over the 9 months of the study, we found that both the groups getting the hour relative to the large control group who did not get the hour had improvements in burnout. Only the group meeting with colleagues had improvement in meaning in work. A year later after the 9-month intervention, the group who had received the hour for administrative catch-up went immediately back to baseline in their burnout, whereas the group that met with colleagues had been vaccinated, if you will, and still had improved meaning in work and lower burnout.

We then tested a different derivative of this that did not occur during the work day but occurred at night. In a second randomized trial,[7] we had physicians sign up in groups of seven or eight other colleagues to go to dinner together where we would have a discussion topic for them. This also had the same benefits of lower burnout and increased meaning in work, and we were able to operationalize that as a standard benefit across all 4000 physicians and scientists at Mayo Clinic.

Another study[8] that was also important and very much focused on the efficiency in the practice environment and giving a sense of flexibility and control was where we looked operationally across all the divisions/departments of Mayo Clinic (150 work units) where we were struggling the most. We went to the lowest-scoring 15%-20% of units and would engage them individually in focus groups. We would give them an opportunity to speak about the broader system issues that were affecting their division for a few moments, but then we would focus inward saying, "What are the things under local control in this unit that are most frustrating for you and that could be fixed if they were prioritized within the local unit?"

We sort of viewed that as the local "broken window." People had to walk pass that broken window every day and they knew what the solution was; they just were not empowered to implement it. When we engaged all those units, we found that after we had those focus groups and met back with the leader of the unit, they would take the lead from that point saying, "This is the domain that we coalesced around what we want to work on first."

They would appoint a task force, develop a local fix, implement it, and assess whether it worked. We found that every single unit we have ever taken through that process has had a substantive improvement in burnout, about a 30% relative risk reduction, and typically large improvements in professional satisfaction. We think it's not only because they fixed the broken window but because they were engaged, empowered, and given a sense of control and ability to co-create their work environment. Even if the first thing we implemented didn't work, we had a process to continually try to improve that local environment.

That was important. We engaged in studies[9] around leadership skills[5] for the local leaders. We have just finished some randomized trials of professional coaching and some other interventions. We tend to look at it from the lens of these driver dimensions and then identify things that would fit the needs of a given organization that might move the needle on one of those. We think of a way to pilot something and then test it, prove its efficacy, scale what works, reject what doesn't, and move on.

Battling the 'Visible Dragon' of the EHR

Harrington: As I listen to you and reflect upon reading your work, it strikes me that the technology explosion in medicine has in many ways (eg, the counting of relative value units or the insistence upon documentation at a very detailed level in the EHR) contributed to the loss of control for some of the things that people might have felt they had.

Maybe the EHR is both the hero of the medical profession by giving us the ability to have data available, but also the villain by making clinicians data entry clerks.

I'm also reminded of a technology-oriented story told by Bob Wachter, who writes in his book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, about the disappearance of radiology rounds as being a key metaphor for how we think about the loss of connectiveness in collegiality. Your solutions and interventions are not technology; they are low-tech interventions. Are you observing that part of what we have lost is some of the humanity? Maybe the EHR is both the hero of the medical profession by giving us the ability to have data available, but also the villain by making clinicians data entry clerks.

Shanafelt: It's a great comment, Bob. The EHR and some of the increased regulation and new measures behind it are well intended but imperfect and only capturing a part of what it means to be a good physician. They add clerical burden for physicians and are certainly major contributing factors.

They also distract from human-human interaction with our patients, which is why we all went into the profession. Not only have they created new work for us, they have changed the nature of our work in ways that aren't always helpful. From a meaning point of view, they have also been part of the creep of scientific management approaches into the profession of medicine—of people counting things that are imperfect proxies and using them to drive productivity or throughput in ways that have not served us well.

Fundamentally, it's easy for us to get distracted by the impact of the EHR. It's the visible dragon in our daily work that has changed things and is easy to blame for all of our challenges. But, as you said, there may be a more low-tech and more humanistic element that has changed and offers us opportunities to make progress without necessarily great expense.

One is connection with colleagues. I often think about some of the interventions that we have done or others have done. The medicine [to treat burnout], if you will, has always been with us; it is our amazing colleagues and being able to support each other and journey together in both the virtues and challenges of being a physician. We don't need to invent the medicine; what we need to do is think about what the modern delivery vehicle for that medicine is. Historically, it might have been the physician lounge, or ways physicians would have more time during the workday to discuss interesting cases. Some of those things are harder to do in today's environment, but we can think about different ways to create the framework for that medicine to be delivered. That is one piece.

A large component is helping physicians remove some of the distractions or at least tie back into the core of the work. What will really help us make progress is to return that physician-patient relationship to the center of our workday and to try to minimize distracting variables that help create risk that we will miss that important part of our day.

A Career Focus Shifting to Clinician Wellness

Harrington: You made a career shift from mostly working as a hematologist investigator with an interest in the whole wellness space to spending the bulk of your time as the nation's first chief wellness officer in an academic health system here in Stanford Medicine. What can we expect to see from you in terms of that career focus shift?

The medicine [to treat burnout], if you will, has always been with us; it is our amazing colleagues...

Shanafelt: It's been an interesting transition. There are many exciting things happening nationally around this dimension right now. We have often used the analogy of the quality movement from 20 or 25 years ago. At that point, there were no chief quality officers. Most hospitals believed they had high quality because they had highly trained and dedicated physicians, nurses, pharmacists, and other professionals. That was their quality strategy.

At some point, vanguard institutions recognized that when they looked at their actual outcomes their quality was not quite as high as they had believed. They began to understand that high quality was not achieved by having top talent and well-educated individuals, but by thinking about how teams function and creating tactics, like checklists and system approaches, so that even if one individual was off their game the system's safeguards went into effect.

I think that is where we now are in this new "movement." We recognize the importance of the well-being of healthcare professionals. Recognizing that allowed me to think about refocusing my energies; the timing was right for this transition. We now recognize that wellness and the well-being of our professionals is not only about personal resilience or just taking care of ourselves with sleep, exercise, nutrition, and so forth. In a sense, that was kind of like the quality movement when we believed it was about having dedicated and well-trained individuals.

'Inflection Point'

Shanafelt: We are now at this inflection point of recognizing how the system, the environment in which we function, is the next frontier for progress. We need senior leaders within organizations to help the organizations accurately assess where they are. Let's benchmark this with other institutions. Let's identify our hot spots. Let's have a coordinated institutional strategy where we can deploy effective tactics and approaches to the units that are struggling most. And let's develop high-level strategies to drive across the organization in thinking about new dimensions of leadership and new dimensions of giving people flexibility and control and helping them engage in work to improve well-being.

We now recognize that wellness and the well-being of our professionals is not only about personal resilience or just taking care of ourselves with sleep, exercise, nutrition, and so forth.

Also, how do we think about true organization-level metrics that our administrative leaders can track as directional-leading indicators and drive improvement that will create the work environment in which our people thrive? It's fascinating to see the journey since Dean [Lloyd] Minor at Stanford created this position. A crescendo of other organizations have followed suit.

I was at the Association of American Medical Colleges' (AAMC's) national meeting, and found that 20 to 25 academic medical centers in the last year have named an associate dean, a senior associate dean, or a chief wellness officer, following Stanford's lead. They are starting to approach this from a system and organizational lens.

We are all still learning from each other in this somewhat nascent field. But it's really exciting to see the momentum and efforts through the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience with the AAMC and Accreditation Council for Graduate Medical Education. They are bringing together payers, regulators, EHR vendors, malpractice insurers, large professional organizations, and leaders of vanguard institutions to work on this in a tiered fashion, recognizing that nobody controls all the levers that need to be manipulated in order to make progress. If we are all at the table and each of us is working on the part that we can control, the potential ability to have real change that makes a difference broadly across the country over the next decade is tremendous.

I think that is where we are going. If we can leave the listeners with any sentiment, it would hopefully be that there is reason for optimism. Discussions are happening with stakeholders who historically would have said this is a personal problem for the physicians and would not engaged with it. But now they are looking at the high levels of regulation, payment, EHRs, and so forth. There is reason for hope.

There is reason for optimism.

Harrington: I can't think of a better way to have summed up our conversation, and there is probably no more critical area in clinical medicine today that needs to be addressed. We are glad and very hopeful that with some of the work being done, locally and nationally, we can see a better future for healthcare professionals.

My guest today has been Tait Shanafelt, who is the Chief Wellness Officer at Stanford Medicine and a professor of medicine here at Stanford School of Medicine. Tait, thank you for joining us on Medscape Cardiology. Maybe we can get you to come back periodically and update our listeners, because this is a topic that is critically important to the cardiovascular community. Thank you.

Shanafelt: I look forward to it, Bob. Thanks for having me today.

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