I consider myself to be incredibly fortunate. From the moment I walked into my first practice session at the the “old” Harvard Community Health Plan to the last day of practice life, I was always part of a team. The constitution of the “team” varied from time to time in response to issues of finance or in response to our efforts to improve our service to patients, but we always believed in the power and necessity of team based care.
Our teams were designed to serve patients, but in retrospect what may have been more important was the support that the team gave to the individual members of the team. Two of our leading academic medical centers, the Mayo Clinic and Stanford, are approaching the issue of clinician burnout as a subject that must be understood if we ever expect to meet the challenge of providing high quality patient care while preserving clinician well being.
I urge you to click on both of the links above to orient yourself to the work that is being done. What is clear is that workforce wellbeing is quickly becoming as big or bigger threat to the future of healthcare and the Triple Aim as are the issues of healthcare finance and the threat to service that challenges our underserved populations. I see some similarities between the issues that add up to create the staggering numbers of burned out or professionally dissatisfied healthcare professionals with the terrifying realities that we now are trying to understand and incorporate into a strategy to combat the opioid epidemic. Let me explain.
As we began to try to understand the opioid epidemic, some of us were surprised to learn that all segments of the population from the very poor to the very wealthy were suffering in a way that was not related to income or social status. We now have evidence from academic medical centers that burnout is a significant issue even in well funded health systems with presumed quality and national reputations, as well as in organizations that care for our most distressed underserved populations. It seems that just as we were slow to appreciate the extent of the opioid problem and turned our back on many of the issues of opioid abuse for more than a decade, we have also been slow to develop the focus, energy, and resolve necessary to begin to even understand the extent of clinician distress or evolve strategies that will effectively address the problem.
In July Stanford published evidence in an online article in the Mayo Clinic Proceedings that burnout does indeed reduce quality and safety. The article from the Stanford News Center explains:
“If we are trying to maximize the safety and quality of medical care, we must address the factors in the work environment that lead to burnout among our health care providers,” said Tait Shanafelt, MD, director of the Stanford WellMD Center and associate dean of the School of Medicine. “Many system-level changes have been implemented to improve safety for patients in our medical workplaces. What we find in this study is that physician burnout levels appear to be equally, if not more, important than the work unit safety score to the risk of medical errors occurring.”
In 2013 Stanford produced a survey that can be easily given to the entire professional staff, including nurses and housestaff, of large health systems. The survey has been improved and verified. It is now available to other institutions. What is also available, for a fee, is an analysis of the results. What is most interesting to me is that the researchers at Stanford have gone beyond the issue of burnout in their analysis. What I like about the current survey is that it looks at “professional fulfillment” as well as burnout. The two are related topics, but not quite the same. As they write:
For the 2016 survey new predictors of physician burnout and professional fulfillment were added and validated (see validation study). This survey was then offered to the entire active medical staff [doctors, nurses, independent practice clinicians, and residents] at Stanford, allowing comparison of a subset who had taken both surveys.
Our survey focuses on the need for professional fulfillment rather than simply the avoidance of burnout. Some of the areas evaluated include perceived appreciation, personal/organization values alignment, peer supportiveness, perceived leadership support, control of schedule, Electronic Health Record experience, self-compassion, sleep-related impairment, and meaningfulness of clinical work.
I like the focus on professional fulfillment. I see it as a higher bar and more effective goal than just reducing burnout. If we are going to “return joy to practice,” we must consider a wider range of issues and solutions than efforts to prevent clinicians from leaving practice, practicing in a way that diminishes quality and safety, or harming themselves. Those are all important objectives, but it feels to me like “shooting higher” for the goal of professional fulfilment is a more positive and exciting objective.
If I break down the list of “the areas evaluated,” I am drawn to “personal/organization values alignment, peer supportiveness, perceived leadership support…” I have confessed a personal paradox in these notes. I was at times overwhelmed and depressed by the workload I experienced in practice, but I always had a great sense of alignment with the mission of our practice and I was “professionally fulfilled.” I appreciated the openness and invitation for participation in problem solving that most of our management conveyed, and I was sustained by my peers, or as I would prefer to say by my immediate teammates and the larger circle of my colleagues. We often disagreed. We often complained together about things that were beyond our control, but in the end most of us could come together to support each other and our common goals. It was an issue of culture.
The smiling faces in the picture with this post belong to the IM team that tolerated and supported my part time primary care practice. By the time I left the team I had worked with some of them for almost thirty years. There was stability in the team for its members and also for the patients who were served by the joint efforts of the team. Our team was “nested” within a larger unit, that was nested with other IM units in a larger IM practice which was nested with other specialties within a medical center, and our center was nested within the larger organization. We were teams within teams. I like to think that our team was nestled within a larger aligned reality like those wooden “Matryoshka Dolls,” from Russia.
Teams provide support and continuity for individual providers as well as for patients. Sometimes your teammates can get you back on track after you have lost your way. When I first began my practice at HCHP in July 1975, I rarely arrived on time for my office hours that were in the afternoon. I would spend the morning at the Brigham, and then traveled a mile away to our offices in Kenmore Square near the “Citgo” sign that overlooks Fenway Park. I was almost always late. When I would arrive 15, 20, or 30 minutes late I would offer the same excuse, “I am so sorry, something held me up at the hospital.” I worked with a wonderful medical assistant who had been a part of the practice since the doors were opened in 1969. She would give me a look that let me know that all was not well as she roomed a patient who had been waiting. This went on for a few weeks. Then one day she said, “Dr. Lindsey may I have a word with you?” I was surprised but responded, “Sure!” She continued, “I know that the work that you do at the hospital is very important, but so is what we do here in the office. It’s hard on me and disrespectful to our patients for you to be late for most sessions. It sends the wrong message.” I was stunned, but immediately knew that she was right. I needed her to be a teammate that cared for the patient and for the message that I was sending.
As time went on I realized that other members of the team often were making a big difference in the care we offered. The medical assistant who took messages also worked the front desk. She knew the practice. She had the uncanny ability to know which patient needed to be seen today and which patient could be seen in a week. The medical assistant that scolded me would often leave a note on the encounter form suggesting that I ask about the patient about her spouse or what was happening at work.
I practiced with only two “independent practice clinicians” over the thirty three years I spent in the office. My first partner was one of the first NPs ever in practice anywhere. She taught me more about caring for patients than all the “attendings” I had as an intern or resident during my training. When she died after a very brief time from an aggressive tumor I was lost. But then I had the joy of working for twenty years with the world’s greatest PA. She is the woman in the blue skirt in the picture.
The challenges that face all of healthcare now and in the future can never be met by any individual clinician alone. The clinicians need to be imbedded in a support team that is respected for their ability to participate in delivering the care and service that every patient has the right to expect. I do not have studies or data to confirm my opinion, but I believe that the relationships that sustained me on my team, and that supported the team within the organization, were the difference between the disabling burnout that I might have experienced and the joy from practice and the professional fulfillment that I can look back on while recognizing what a lucky fellow I was to have been a part of a team that made a difference.
I do not know what the answers coming from Stanford and the Mayo Clinic will be, but I will be skeptical of their methods and analysis if they do not identify the benefits of team based care for both professionals and patients. I do not hear the term “medical home” as often as I did a few years ago, but I do believe that our team was a nurturing “medical home” for me as well as for our patients.
