Restoring the Joy of Medicine One Stressor at a Time

Maureen Salamon

October 16, 2019

Caroline Gérin-Lajoie, MD, is the daughter of a doctor and a nurse who was raised to feel a bone-deep pride in the quest to help others. But it was not until she became a doctor herself that Gérin-Lajoie grasped the importance of resilience.

"Working as a psychiatrist in a large hospital dealing with cancer patients made me appreciate some of the difficulties and limitations in the system," said Gérin-Lajoie. "I also see parallels in cancer care and psychosocial oncology. We talk about the theme of resilience — aiming to thrive, not just survive — and I've been able to see how that parallels some of the issues in physician health and wellness."

Caroline Gérin-Lajoie, MD, Canadian Medical Association. Lajoie translates from French to the word joy.

The effect of burnout — long-term job stress that leads a person to feel exhausted, overwhelmed, cynical, detached from the job, and lacking a sense of personal accomplishment, according to the Medscape National Physician Burnout, Depression & Suicide Report 2019 — on clinicians has increasingly been in the spotlight in recent years, and has been the subject of research for the past decade (Mayo Clin Proc. 2019;94:1681-1694). In the 2019 Medscape report, 44% of physicians reported feeling burned out and 4% reported being clinically depressed.

Organizations like the Canadian Medical Association (CMA) — where Gérin-Lajoie is vice president of physician health and wellness, a first-of-its-kind position in Canada — are now making an effort to take accountability for fixing the factors underlying burnout.

"For the CMA, it was the recognition of 10 years or more of research demonstrating that physician burnout is an issue that is increasing and related to patient outcomes and quality and safety," said Gérin-Lajoie, who is also medical director of physician health and wellness at The Ottawa Hospital and director of faculty wellness at the University of Ottawa in Ontario, Canada.

"More and more physicians and medical trainees were reporting distress, and we could no longer deny that physician wellness is an issue that needs to be addressed," she told Medscape Medical News.

At the CMA, Gérin-Lajoie helms a formal physician wellness team and a first-ever national analysis of the processes, groups, and structures involved in physician wellness in Canada, where 30% of physicians and residents reported high levels of burnout in a recent survey.

The CMA is hardly alone. It joins major medical organizations in the United States and elsewhere that have dedicated leadership positions that encompass or focus solely on physician well-being, the catch-all term often used to describe burnout.

Undeniable Distress

Christine Sinsky, MD, American Medical Association.

"My observation is that we're approaching a tipping point. Talking about burnout is becoming normalized and addressing it is becoming socialized as a responsibility of organizations," said Christine Sinsky, MD, vice president of professional satisfaction at the American Medical Association (AMA).

"There are no quantitative data on how many healthcare organizations are intentionally addressing the issue. I feel we've been part of the movement that is growing, and growing at a faster pace than it was 5 years ago," she explained.

Sinsky's husband has dubbed her the "veep of joy," which might not be too far off, she said. In fact, her focus on physician wellness began about 5 years ago, 2 years before she took on her current role at the AMA.

Since 2012, the AMA has implemented an array of initiatives related to physician burnout, including a Joy in Medicine program, which in September of this year recognized 22 healthcare organizations for trying to improve the well-being of their workforce. Their efforts are meant to serve as a "roadmap" for others, Sinsky said.

Clif Knight, MD, American Academy of Family Physicians.

At the American Academy of Family Physicians (AAFP), Clif Knight, MD, senior vice president for education, champions the Physician Health First initiative.

After the release of startling national data 5 years ago, which showed that the burnout rate among family physicians was 63% (Mayo Clin Proc. 2015;90:1600-1613), the AAFP launched a deep dive into the issue, Knight said. Efforts include the Physician Health First portal, which AAFP members can use to develop a personal plan to improve well-being and professional satisfaction. And in 2018, the AAFP held its inaugural annual Physician Health and Well-being Conference.

"I've gotten notes from people who've attended who said they were ready to quit medicine and now are much happier because of things they took away from the conference," said Knight, adding that the AAFP offers maintenance certification credit to attendees who develop a personalized plan for the changes they want to implement in their practice, organization, or personal life.

In recent months, the National Academy of Medicine and other American organizations have proposed that all hospitals and healthcare systems create executive-level wellness roles. Several such organizations, including Kaiser Permanente and Stanford Medicine, have appointed chief wellness officers in the past few years, according to a recent report (CMAJ. 2019;191:E267), which is a key indicator of how seriously the issue is being considered, said Sinsky.

The Stanford Medicine WellMD Center offers a 1-week chief wellness officer course aimed at senior leaders with organization-wide responsibilities to promote expertise in principles contributing to physician well-being.

Canadian research on the issue needs to "catch up" to American efforts, Gérin-Lajoie acknowledged, noting that she is not aware of any chief wellness officer positions in Canadian hospitals.

However, she pointed out that hospitals "sometimes combine the role of physician wellness leader into the chief of staff, or blend the role, with someone focusing on diversity, equity, or professionalism."

Tackling Burnout

About 7 years into her career as a general internist, which lasted more than 3 decades, Sinsky said she realized she was spending a lot of time on tasks that did not add value to her interactions with patients. As a result, she re-engineered work flows and changed the makeup of her office staff.

But not all physicians have the autonomy to adjust their workplace environment, which has been identified as one of several core contributors to burnout (Ann Intern Med. 2009;151:28-36). Long hours, too many administrative tasks, and electronic health records are also culprits, according to the 2019 Medscape report.

"I think that agency over the nature of how I did my work was a big part of why I was able to have a 32-year career with less-than-average" causes for burnout, Sinsky told Medscape Medical News. But some physicians are "spending their days doing the wrong work," devoting hours to clerical tasks, which pushes "the work they want and need to do for patients to the margin."

The burden of extraneous, onerous tasks makes it difficult for physicians to find meaning in their work, which Gérin-Lajoie described as a "protective factor" against burnout.

Potential solutions must address both the individual and systemic factors driving the problem.

Resilience training — which promotes personal care, such as meditation, yoga, exercise, sleep hygiene measures, and other stress-reduction techniques — was one of the first tactics developed to reduce physician burnout and still figures prominently.

The AMA launched STEPS Forward, an online hub with more than 50 training modules focused on improving factors such as resilience and practice workflow, managing stress, and preventing burnout and suicide.

But these approaches "don't change all of the system factors," Knight told Medscape Medical News. "It's short-sighted to treat this as a problem that can be addressed at the individual level."

Sinsky agreed. "I see burnout as a symptom of the external environment in which physicians practice," she said. "I think some react negatively to the term burnout because they feel judged by that term. It is my observation that about 80% of burnout is driven by systemic factors and only 20% by individual factors."

It's short-sighted to treat this as a problem that can be addressed at the individual level.

Some organizations began addressing physician burnout in their workforces by having physicians work in silos, but systemic efforts must promote collaboration, Gérin-Lajoie said. To that end, even the youngest doctors are targets of the CMA Ambassador Program, launched in 2018 to build a community of advocates.

The program, which currently has 45 participating medical students, residents, and junior career physicians, was presented at the American Conference on Physician Health, hosted jointly, last month, by the AMA, the Mayo Clinic, and Stanford Medicine.

"We want to invest in these new generations of learners and physicians to become agents of change so we can continue to improve our environments and culture in the years to come," Gérin-Lajoie said. "The hardest part to change will be our medical culture."

But changes to that culture are slowly starting to happen.

An 11-point call to action was issued by 10 chief executive officers of American healthcare delivery organizations after a 2016 summit. The leaders committed, among other things, to consistently measure physician well-being at their own institutions using standardized benchmarks and to understand and broach the clerical burden and misallocation of tasks affecting physicians.

A 2017 initiative of the National Academy of Medicine (NAM) — the Action Collaborative on Clinician Well-being and Resilience — is working with more than 180 organizations to reverse the trends on physician burnout. A consensus report from this collaborative — the result of six working groups meeting over 4 years to identify evidence-based strategies to improve clinician well-being at the organizational and systems levels — is expected this fall.

Sinsky and Knight are participants of various working groups, which focus on tactics such as leadership engagement, organizational best practices, and breaking the culture of silence.

Victor Dzau, MD, National Academy of Medicine and chair of the Action Collaborative.

"Physicians aren't the only group facing this, it's all clinicians," said Victor Dzau, MD, president of NAM and chair of the Action Collaborative. "It needs more visibility, but a big piece of the solution is going to be system change and not blaming the individual for the problem."

The Action Collaborative came about in response to "a groundswell of concern from many organizations," Dzau told Medscape Medical News.

An alliance of the AMA, the CMA, and the British Medical Association (BMA) led to the biennial International Conference on Physician Health. The abstract review committee for the 2020 conference next September in London is comprised of five representatives from Europe and 10 from non-European countries, said Tom Rapanakis, head of wellbeing support services at the BMA.

"Obviously, the challenges faced by each country can vary, depending on different healthcare models, but examples of best practice can still be shared," Rapanakis told Medscape Medical News. "Also, by identifying themes shared across different models, you can differentiate between problems that might be inherent to doctoring and those that could be solvable by local systemic changes."

Gérin-Lajoie reports receiving grant funding from Mach-Gaensslen Foundation in her role at The Ottawa Hospital. Sinsky, Knight, Dzau, and Rapanakis have disclosed no relevant financial relationships.

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