12 July 2019

Dear Interested Readers,

 

Flipping the Conversation From Burnout to Joy

 

Almost two years ago I reviewed  The Patient Centered Value System: Transforming Healthcare Through Co-Design by Anthony M. DiGioia and Eve Shapiro. Then a little over a year ago I passed along a request to you from Eve Shapiro, who is an “Interested Reader” and frequent commenter on these notes. Eve had asked me for help contacting healthcare professionals,  “…doctors, nurses, and others” from the front lines of patient care who would be willing to be interviewed for thirty or forty minutes on the telephone. I wrote that the interviews would “focus on what providers say they need in order to experience joy and meaning in work–specifically under what circumstances they have experienced it (or not), what promotes or inhibits it, and what people say they need in order to realize it.”

 

The quotations are around phrases that I lifted from Eve’s note of request to me. Well, a year has passed and the interviews have occurred. From time to time over the last year Eve and I have exchanged emails about what she was learning from the interviews. I could tell from her comments that she was somewhat surprised by what she was learning. About three weeks ago Eve wrote again in response to my post entitled “Finding Joy in Practice.” 

 

In her note she said that the interview process was completed and that she was well into the writing of the book. Given what I had said in my post about joy in practice she thought that I might be interested in reading a preview of what she had learned in her interviews. Attached to her letter was a first draft of the preface and introduction of her book. She promised to send the full draft of the book soon and said that it would be published early next year. Most importantly, she wanted me to know that it was fine with her if I began to share what she had discovered in the more than 100 interviews. She described just who she had interviewed in the draft of the preface:

 

…They are primary care doctors, ER doctors, pediatricians, radiologists, and specialists; registered nurses, nurse practitioners, nursing directors, and nurse educators; CEOs, medical directors, pharmacy directors, and quality managers; physical therapists, psychologists, psychiatrists, social workers, and an integrative massage therapist; physician assistants, office managers, EMTs, technologists, and a woman who cleans an operating room; experts in the field of physician burnout; and others. 

 

These professionals have in common only that they work in healthcare in some capacity. They have worked at their jobs for different lengths of time. Some are residents and some are retirees. They come from different ethnic backgrounds, are gay and straight, and work in urban, rural, and community settings in the North, South, East, West, Midwest, Southwest, and Puerto Rico. They serve diverse populations of insured, underinsured, and uninsured. They treat those who are wealthy, those who are employed, unemployed, and struggling. They serve the homeless, immigrants, and American Indian tribespeople. They deliver care in solo, large, and small group practices; hospitals; academic medical centers; community health centers; and large, small, and medium-sized integrated health systems. These healthcare professionals shared their enthusiasm, joys, frustrations, disappointments, insights, advice, stories, and pain in conversations lasting anywhere from 30 minutes to 3 hours. They explained what it looks and feels like to work in healthcare today no matter who you are, where you work, or what your position is in the organizational hierarchy…

 

Just the description of the effort is impressive. The interviews were structured around a list of twenty questions. So that you can consider the same questions, I am going to give you the whole list. I bolded the thirteen questions that I think are likely to yield the most interesting information. The other seven will yield important demographic information. I guess I will have to wait until Eve shares the whole book with me to know just how “my favorite questions” were answered. 

 

· What is your degree and job title?

 

· Where do you work now, in what capacity? Where else have you worked?

 

· What does your job entail?

 

· How long have you done this work?

 

· When and why did you choose to go into healthcare? This particular Area?

 

· What are your hours?

 

· How do you define joy in work?

 

· What diminishes joy in work for you?

 

· Do you ever feel overloaded by work?

 

· Do you feel you have control over your time, work environment or Workload?

 

· When something goes wrong, what happens in your organization?

 

· Do you feel a tension between meeting patients’ needs, your own needs, and the needs of your bosses  and administrators?

 

· Is there a relationship between money and joy?

 

· Do you feel sufficiently rewarded by your administrators, bosses, and colleagues for your work?

(aside from money—recognition, gratitude, etc.)

 

· Is there something the administration could do to enhance your joy in Work?

 

· Do you think there is a connection or a disconnection between what you think of as problems

and what the administration thinks?

 

· If you could change anything about your job (any number of things) what would it be?

 

· What advice do you have for your bosses? Colleagues?

 

· What else would you like me to know?

 

· Do you have any colleagues who might be willing to talk to me?

 

I think it is important for you to know exactly how Eve structured the interviews, and how she chose the people she interviewed. She is very straightforward about the fact that her intent was not statistical significance. She is most interested in sampling attitudes about job satisfaction and “joy” from professional activity. She was not looking to add to the body of information about “burnout.” 

 

I did not reach out to groups whose mission is to help physicians cope with burnout because I did not want burnout to be my focus. Joy and what it takes to achieve it is my subject. Other books and many articles have focused on burnout admirably. My goal in writing this book was to learn what promotes and inhibits joy in work among a wide range of healthcare professionals, each of whom is vital to patient safety and the efficient running of any healthcare organization.

 

She catalogs some of the things she learned from the interview. I have formatted her key findings into bullet points and have bolded the key words:

 

• Joy in work means different things to different people. To some, joy is a spiritual experience. Joy can mean delivering a baby; forging a relationship with a patient; comforting patients and families; making patients well or better than they were; saving a life; teaching and mentoring students; or simply having a patient say ‘thank you.’ Some said joy is doing a job supported by colleagues, supervisors, and mentors—being part of a team. To others joy means being unaware of the passage of time; a sense of peace; of taking satisfaction in doing one’s best; and, as one OR nurse told me, being dog-tired with swollen feet at the end of the day.

 

• Joy often emanates from within. Their abiding joy is sustained by their love of their chosen field and whatever it was that drew them to healthcare in the first place. Some of them talk about their work with enthusiasm and effervescence; others with earnestness, focus, and commitment. Many say their tenacity and resilience are essential for overcoming inevitable obstacles, frustrations, setbacks, and failures. For these people, the glass is always half full, regardless of transitory circumstances.

 

• …the workplace can either promote, diminish, or destroy joy in even the most  positive people. For those I interviewed, when joy is diminished or destroyed it is always destroyed from the outside. 

 

• …joy is eroded by the stressful nature of the work itself; pressure by administrators who fail to listen and who put “relative value units” over clinicians’ time with patients; by the lack of autonomy and control over one’s schedule, one’s time, and one’s tasks; the expectations and demands of payers; lawsuits and the fear of lawsuits; fear of being fired for speaking one’s mind; disillusionment when speaking one’s mind leads nowhere; disrespect from administrators and co-workers; and the moral and emotional distress that results when one’s values conflict with those of the organization. 

 

Those are findings and observations that suggest to me that the flip of joy is not burnout. It will be interesting to see whether or not the complete analysis of the conversations supports that preliminary conclusion. 

 

Eve lets her interviewees speak for themselves. From their answers and descriptions she reports that “joy” is possible even in the presence of problems. Problems alone do not extinguish “joy” and one might surmise that we must look beyond “problems” to fully understand what diminishes joy or creates burnout. 

 

Nevertheless, many of those who shared their stories explained how they manage to find joy when and where they can. Dissatisfaction is common. Burnout is rare among those I talked to.

I was surprised to find burnout in only one physician I interviewed, and she is retired. Why only one? Where were all the burned-out physicians that others have written about? The retired, burned-out physician who contacted me to talk described being burned out as walking dead–her own take on the Maslach Burnout Inventory. A volunteer EMT described the burnout of  a colleague as being equivalent to post-traumatic stress disorder. This man’s emotional state was so fragile that the EMT was unwilling to ask him to talk to me. Those who were willing to talk about joy in work or the lack thereof seemed then, by definition, not burned out—in essence, a self-selected Group.

 

Clinicians know that denial is often associated with disease or dysfunctional behavior. As a cardiologist I frequently observed that patients who should have had angina did not. I finally realized that many did not have angina because they had stopped doing the things that had made them uncomfortable. After that insight, I stopped asking people about chest pain and started asking them about their activities. Alcoholics frequently deny that they have a drinking problem. The joy/burnout connection may be stronger than the interviews suggest because in the interviews burnout would have been a self diagnosis. That reality makes Eve’s decision to ask about “joy” rather than burnout such an interesting choice of methodology and may make the information gained from the interviews much more valuable. One concern that stands out and may represent something that is an infrequently discussed problem is the “pervasive fear” that she identified.  

 

Most of the dedicated men and women who told me their stories did so on condition of anonymity for fear of losing their jobs or otherwise being retaliated against. Those who wished to remain anonymous did not want their institutions to be identified or hinted at: most did not want to be identified by city or even by region of the country. This pervasive fear is a theme that runs throughout the interviews that follow. I have respected their wishes so I could learn about their experiences and perspectives and share them with others. Those who agreed to have their names, degrees, and institutions identified clustered at the top of the healthcare ladder, primarily CEOs and medical directors.

 

She calls her interviews “snapshots, ” and believes that they do reveal what sustains joy and what undermines it. Joy seems to be sustained by internal, pre existing strengths that can be augmented by positive externalities. As noted earlier, she observed that joy was diminished by negative events and externalities.

 

On the positive side:

 

What promotes and sustains joy in work seems to stem from one’s internal characteristics –enthusiasm, tenacity, resilience, and passion for one’s chosen profession–combined with some fortuitous external ones, such as living and working in alignment with one’s core values; having autonomy and control over one’s day; working in multiple roles, especially when one of these is teaching or mentoring; having supportive bosses and colleagues; and insistence on finding work-life balance.

 

On the negative side:

 

What diminishes joy in work is pressure, stress, and fatigue brought on by the nature of the work and the culture of the workplace; administrators who have little open, two-way communication with clinicians and whose first priority is the organization’s bottom line; the insult implicit in a doctor’s having to ask administrators for 5 more minutes with their patients; and the disrespectful treatment of doctors by administrators, of nurses by doctors, and of EMTs by nurses in an industry known for its hierarchical culture–one in which bad behavior by those who bring in the most money is tolerated while the collateral damage they inflict on professionals and patients is too often ignored.

 

If you are wondering about the relationship of the EMR to joy and to burnout, she has answers for you:

 

What destroys joy in work, especially for older physicians, is the autonomy and control that the electronic medical record (EMR) has erased…For most physicians regardless of age, the burden of the EMR increases as the number of patients they are required to see each day grows… Conflict between one’s values and the tactics, policies, and attitudes of the enterprise creates a tension that invariably destroys joy. 

 

It may surprise you, and perhaps it is hard for you to accept, that the issues in those last two paragraphs diminish joy, but don’t necessarily cause burnout. Perhaps we’ve had it wrong all along. Burnout may be one thing, and decreased joy from work may be a separate concern which deserves different considerations.  

 

I think it is very important to note that the professionals who were interviewed did frequently express a sense of moral injury and did describe emotional distress. They just did not see their own complaints as evidence that they were burned out. I described the impact of “moral injury” in a close friend and colleague in a post four years ago. Eve describes the problem well, and in a way her description matches the experience that my colleague and friend experienced. It is interesting that he left our organization after his experience. She found the same reality, moral injury causes many people to leave an institution that violated their values. Leaving a place that offends you may prevent burnout. 

 

Moral injury and emotional distress, clinicians of all kinds say, never fails to destroy joy in work. Moral injury and emotional distress result from the collision of one’s personal, deeply held, core values with the organization’s demands and expectations. One can tolerate only so much. When the tension between what one believes and what one is expected to do becomes untenable, clinicians leave. If they don’t, they burn out.

 

I am eager to see the completed book. She hints that there are surprises ahead, or maybe it is that we will be surprised to learn more about the paradoxes associated with joy and organizational dysfunction that is ameliorated by clinicians and other healthcare professionals who are willing to put professionalism and their chosen obligations to patients before their self interests. There is the possibility that we are able to tolerate dysfunctional systems because of the nobility and heroism of the majority of professionals who make a commitment to patient care their highest priority.

 

….a dermatologist working in an integrated healthcare system once told me, “I love my work but I hate my job.” This sentiment was echoed by many people intent on salvaging some joy and meaning from their day even when they have to fight multiple forces to do it. Some find joy in caring for patients but clearly struggle to recognize it in the face of stress, fatigue, being treated with disrespect, or spending late nights with the EMR. Too many love what they do in spite of–not because of–their workplace or their supervisors and administrators. Many people work hard to find meaning in their day when they could just as easily be ground down by their dysfunctional environments, as some are…According to a number of healthcare professionals I interviewed, the leaders of such organizations know that healthcare professionals’ love of their work, concern for their patients, and vestment in retirement plans will keep them in their jobs regardless, making the need to improve a matter of little urgency…

 

That last hypothesis is a real concern for me and was the source of another recent post that I wrote in response to the same contention in a New York Times op ed piece by Dr. Danielle Ofri of Bellevue Hospital and NYU.

 

What is Eve Shapiro’s objective? What does she hope that her interviews and analysis will do? She articulates a higher purpose than just adding more data to what we already know is wrong with our approach to healthcare delivery and workforce issues when she says:

 

Most of these interviews could easily have fit into more than one category. There is certainly overlap, with multiple themes addressed by almost everyone. What I perceived to be the strongest theme guided me in placing the interviews where they are. I hope these interviews will help healthcare professionals of all kinds to acknowledge and respect each other, and to see that they are more alike than different when it comes to what promotes, diminishes, and destroys joy in work–regardless of age, gender, ethnicity, degree, or their place in the organizational hierarchy. I also hope these interviews will prompt administrators to rethink their values, communications, and expectations; increase appreciation for those in healthcare who tend to be undervalued and invisible; and continue to inspire the search for improvement among healthcare leaders across the country.

 

You can be sure that when I read the entire manuscript, I will pass on what I learn to you. One of my favorite parts of my former corporate responsibilities was to attend our annual awards dinner. I was inspired, and given an infusion of hope when I heard the stories of clinical commitment and service that were associated with the awards. There is a tight association between the stress of the responsibility for other lives, and the joy of being a participant in the long and continuing story of giving care to others. I am definitely expecting to be inspired by this book.

 

Summer Is So Sweet and So Short, I’m Trying to Savor Every Opportunity It Offers

 

One big advantage to retirement is that when I wake up at 5 AM now I don’t have to get up and get ready for work. Usually I just say a little prayer of thanks that I can go back to sleep for as long as I wish. I also offer up a prayer requesting mercy for all of the people who are getting up to go into hospitals or outpatient offices to give care to patients. My prayer includes all of those who are headed to administrative offices, and are likely to be forced to endure one or more PowerPoint presentations before I finally get up and begin my morning routine of coffee, several newspapers, and emails after I catch up with all my ongoing games of “Words With Friends.” 

 

For some reason earlier this week, the week of my 74th birthday, I awoke a little after five, and had the urge to look out at the lake. I think I was wondering about what to expect from the weather. I did not expect to see a spectacular sunrise that was a virtual bookend to all the lovely sunsets that I enjoy. Today’s header is not a sunset. It is a summer sunrise of spectacular beauty. 

 

Summer is short. It is sad to say that the sun is already rising later and going down sooner than it was just two weeks ago. I am walking and swimming every day. I have two sailboats, an old motorboat, and my fishing kayak that I try to use regularly. My days are full of summer activities. It takes a lot of attention to keep potted plants on the deck from getting too dry. We have house guests most weekends. Gershwin was right when he wrote “Summertime and the living is easy…,” but he forgot to mention that it was so busy, and that would have rhymed, but even in that lullaby you get this sense that things will eventually change:

 

One of these mornings

You’re going to rise up singing

Then you’ll spread your wings

And you’ll fly to the sky

 

But till that morning

There’s a’nothing can harm you

 

Well, summertime and life both have their limits, so don’t make the mistake of deferring the opportunity to enjoy as many summer sunrises as possible. I am going to try to enjoy a lot more of them, and then go back to bed to rest up for all the things I am planning to do in the afternoon. I hope that you have a rewarding strategic plan for the summer. Be careful not to wait until you are retired to take in a lot of sunrises. 

 

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

 

Gene