Brighter Days Ahead

From the Winter 2018 edition of Vanderbilt Medicine Magazine

Illustration by Simon Shaw

 

It was like a switch flipped.

One month, Ryan Bayley, MD’08, was practicing emergency medicine with the energy and joy he had experienced for years. The next month, his shifts had become drudgery.

It was the final year of his emergency medicine and EMS fellowship training in New York City. It was the last year of a pathway he had been on for 13 years, starting with several years working as a paramedic, followed by medical school at Vanderbilt, residency and fellowship.

“I was doing exactly what I had envisioned for myself, but I was physically struggling to recover between shifts, and the challenges of daily practice were wearing me down more than I expected,” Bayley recalls.

“I attributed it to residency and fellowship being a pretty long haul and thought that things would improve once I was out on my own.

“And they just didn’t.”

Bayley was suffering from burnout, but he didn’t recognize it.

More than half of the physicians in the United States report symptoms of burnout — a syndrome of exhaustion, emotional detachment from one’s work and reduced sense of personal accomplishment.

“There is a recognition nationally that there is a problem in medicine,” says Reid Thompson, MD, William F. Meacham Professor and Chair of Neurological Surgery. “Whether burnout is a new problem is not clear, but what is clear is that it seems to be on the upswing.”

Vanderbilt University Medical Center (VUMC) has established a task force to address the issue and seek ways to improve physician well-being. Thompson and Mary Yarbrough, MD, MPH, associate professor of Clinical Medicine and executive director of Faculty and Staff Health and Wellness, are co-leading the effort.

“I would argue that the institutions that will be successful going forward will be the ones that have addressed this problem head-on and have developed strategies to mitigate physician burnout,” Thompson says.

 

The problem of burnout

Although occupational burnout was described in 1974, and a psychological tool for assessing its symptoms was published in 1981, the first large-scale national study of physician wellness in the United States didn’t happen until 2011.

That year, Tait Shanafelt, MD, and colleagues at the Mayo Clinic and the American Medical Association invited about 27,000 U.S. physicians to participate in a survey using the Maslach Burnout Inventory, a 22-item questionnaire that measures the three dimensions of burnout.

They found that among the 7,288 physicians who completed the survey, 45.8 percent reported at least one symptom of burnout. The highest rates occurred in specialties at the front lines of healthcare: emergency medicine, general internal medicine and family medicine.

Burnout was more common in physicians compared to working adults in other fields, and physicians were almost twice as likely as other workers to be dissatisfied with work-life balance.

Three years later, the situation was worse.

Shanafelt and his colleagues conducted another study in 2014 and found that among 6,880 physicians who completed the survey, 54.4 percent reported at least one symptom of burnout, an increase of nearly 10 percent compared to 2011. The percentage of physicians satisfied with work-life balance dropped almost 10 percent. Working adults in other fields had minimal changes in burnout satisfaction with work-life balance.

Other studies have linked physician burnout to higher rates of errors, infection and mortality in hospitalized patients.

“It’s clear that physicians are strained,” Yarbrough says. “The healthcare system and demands on physicians have changed dramatically in recent years.

“We have more pressures, more technology, more documentation, different ways that people are communicating with us, electronic medical records to navigate, quality metrics to meet, patients grading us. The list goes on and on, and there’s a toll for each of these things.”

Documentation requirements have become particularly onerous, says Thompson, with layers upon layers being added and nothing being subtracted.

According to a study published in the September/October 2017 Annals of Family Medicine, primary care physicians spend more than half of their workday interacting with electronic health record systems during and after clinic hours.

“All these things seem to be pulling us away from what brought us to medicine in the first place — the fact that we like taking care of patients,” Thompson says. “More and more, we’re not doing that. We’re spending hours charting things — including late hours at home ‘pajama charting.’ That’s not great.”

 

A paradigm shift in medicine

At Vanderbilt, the VUMC Task Force for Empowerment and Well-being, led by Yarbrough and Thompson, is tackling the issue of physician wellness. The 16-member multidisciplinary group opted for a name that reflected its desired focus.

“We want to find ways to empower physicians to take control of this issue,” Yarbrough says. “What is it that physicians need in order to find meaning and enjoyment in their work? Our focus is on well-being and prevention.”

The task force asked Vanderbilt physicians to complete an online survey with two questions:

Vanderbilt is not immune to burnout, say task force co-chairs Reid Thompson, MD, and Mary Yarbrough, MD, but there are programs in place to help. Photo by Joe Howell.

“As a physician in the VUMC community, what do you need to do your best work and enhance your personal well-being?”

“If 10 reflects your optimal health and wellness and 0 reflects burnout or significant professional stressors or concerns, where do you place yourself on this scale?”

About half of VUMC physicians rated themselves below 5 on this scale, consistent with national findings on physician burnout.

“We’re not immune from this problem at Vanderbilt,” Thompson says.

The VUMC survey revealed broad themes that physicians identified in naming needs for their best work and personal well-being. The most mentioned needs included self-care, staffing support, leadership support and autonomy.

For its initial recommendations, the task force looked for enhancements that could happen relatively quickly. Some examples: adding wellness to the VUMC Credo, encouraging physicians to see their primary care providers, addressing childcare hours and addressing parking needs for on-call physicians.

Other recommendations will require more study of staffing needs, leadership training on wellness, guidelines for the meaning of time away from work and tracking implementation of changes.

“We’re starting a conversation and calling attention to these needs,” Yarbrough says. “I think we’re in the middle of a paradigm shift in medicine where we’ve got to step back and think about how we structure our practices. What are the things that we really need doctors to do, and what are the things that might better be done in other ways?”

Thompson envisions Vanderbilt leading the way to big changes in efficiency.

“I think the problem boils down to time and how our time gets eaten up by things that pull us away from the things that give meaning to what we do and to our lives,” he says. “The task force is focusing on how we can make physicians’ lives here much more efficient to buy back time for them.”

That might mean adding scribes to the care team or leveraging technology to have an automated system taking notes in the background as physicians see patients.

“How can we invent that here?” Thompson says. “How can we be leaders nationally in developing strategies that empower physicians to get back to what they find joyful in their careers and in their lives?”

 

“I wondered what was wrong with me.”

Faced with exhaustion and detachment during his final year of training, Bayley did what physicians do — he attempted to diagnose the problem.

He saw his general practitioner to test for endocrine disorders; he visited a sleep specialist; he consulted a psychiatrist.

“Even though I was apparently physically and mentally healthy, I was struggling to feel rested enough to show up at my next shift, and I had lost the sense of connection with patients and colleagues,” Bayley recalls. “I wondered what was wrong with me and why all of the other residents and physicians seemed to be enjoying the work and having no difficulties.”

He continued to suffer, devising ways to avoid the stresses of clinical practice and protect his limited energy, until he happened into an opportunity to work with an executive coach who specialized in burnout and fulfillment.

“The coach had never worked with a physician before, but he was willing and I was desperate.”

Coaching — a structured process of reflection, goal-setting and skills development — made it possible for Bayley to “really step back and be fully conscious and objective about the things that were going on in my life,” he says. “At that point, it became pretty obvious that I was experiencing burnout. I knew the triad of exhaustion, depersonalization and loss of efficacy, and I met those criteria.”

Through mindfulness and other techniques, coaching helped Bayley develop skills to better manage the “inevitable challenges that come with practicing in the current healthcare system,” so that he was able to practice emergency medicine again “and really enjoy the job.”

“When you’re burned out,
it’s very easy to start focusing all of your time and effort
on avoiding any further
depletion.” – Ryan Bayley, MD

He also re-prioritized his health and became more intentional about how he spent his time, particularly with his children, he says.

“I was able to balance my professional life with other areas of my life that had gotten neglected along the way.”

Impressed with the impact coaching had on him, and now recognizing the same symptoms in physicians all around him, Bayley trained as a professional coach and began to coach physicians part-time while continuing to practice emergency medicine.

He now coaches physicians full-time and consults with healthcare institutions on physician well-being and performance. Bayley works with physicians all over the United States, generally by phone or video conference two to four times per month for an average of eight months, although some clients require just a few sessions to work on a very focused challenge.

Coaching creates an objective and safe space for physicians to step back and work on themselves and their well-being, Bayley says. He helps his clients understand what is important to them, what is getting in the way, and how to make changes to reclaim control and satisfaction.

The work has given him insights into his own experience during his final year of training, he says.

“I’ll think back and realize, oh, that behavior was really a manifestation of trying to avoid a difficult thought or feeling about work. When you’re burned out, it’s very easy to start focusing all of your time and effort on avoiding any further depletion. Life becomes about avoidance.”

Take, for example, Bayley’s experience in an emergency department during cold and flu season.

“You can imagine that a doctor has lots of difficult conversations about why a patient doesn’t need antibiotics or doesn’t need to be admitted to the hospital for a cold,” he says. “Then that patient storms out of the ER calling you an idiot. That’s depleting.”

Bayley found himself speeding through exams of the “worried well” and prescribing antibiotics. In the moment, it felt like success: no arguments, no disgruntled patients, high throughput. But longer-term consequences soon kicked in: concerns about antibiotic overuse, not educating patients in a way that empowers them, not practicing good medicine.

“That really is a hallmark of burnout — when you’re tangled in the difficult thoughts and feelings that are a normal part of daily medical practice and you start to spend your time and energy avoiding them, but you do so in ineffective ways,” he says. “You’re in a blind spot where ‘problem-solving’ actually fuels the problem, and eventually one of those actions catches up with you.”

 

Institutional culture change

The culture of medicine, Bayley argues, contributes to physician burnout.

“There’s a hidden curriculum during medical training — all the behaviors and attitudes of senior physicians that pervade the profession,” he says.

Ideals like service, responsibility, excellence and autonomy can have a dark side as they morph into obligation, being present for work but not fully functioning because of illness or other conditions, perfectionism, work compulsion and isolation.

“All these things together create a culture of people competing with each other to work harder: who gets in earlier, who stays later, who can push themselves the hardest, who’s strong enough not to show any weakness,” Bayley says. “The culture sets up barriers to admitting you need help and to seeking help.”

Changing the culture to promote wellness is possible, Thompson says. He’s done it in his department.

Thompson points to a trophy on the table in his office. It’s a model skull — containing a softball — that is awarded to the winning team of neurosurgeons participating in an annual charity tournament in Central Park. The highly competitive event draws teams from all over the country. Vanderbilt’s Department of Neurological Surgery won the tournament this year.

“We’ve been focusing on wellness with our residents, doing things like this tournament, whitewater rafting and camping, and we’ve achieved national recognition for our efforts,” Thompson says. John Wellons, MD, professor of Neurological Surgery and director of the department’s residency program, was invited to give a presentation about the wellness curriculum at the 2017 meeting of the Society of Neurological Surgeons, which includes program directors and department chairs from every academic medical center in the country.

“I know that you can change the culture if you start talking about well-being, thinking about it, modeling it and holding people accountable,” Thompson says. “If your focus is a culture of well-being, there’s a lot of good that comes from that.”

An institution promoting a culture of wellness would address issues in self-care, child care, eldercare, pay equity and reduction of unconscious bias, Yarbrough says.

It might mean that departments have a chief wellness officer and that department meetings include discussion of wellness initiatives, Thompson adds. It could mean that in addition to focusing on clinical work, research and teaching, mentorship of residents and young faculty might include a focus on wellness — a “fourth leg” of mentoring.

“That happens in pockets, but if it happened institution-wide, that would move the dial to the goal of becoming that place where people want to come and where they want to stay.”

Thompson says he’s honored to be part of the VUMC task force and that its work may be the most important of his career.

“The direction that things are heading with this alarming rate of physician burnout makes it critical to develop strategies to mitigate that, to turn it around. I think it will be a lasting contribution.” n