Monday, April 22, 2013

Provider/Physician Burnout: Taking The Battle to the Brain

Our Coach+Leader blog helps you have a greater impact on improving care. It offers healthcare leaders sound perspective, road-tested tips and tools that remove unneeded complexities... allowing leaders to focus on what matters most to patients. Every so often we hear about exceptional people doing exceptional things and believe it is important to share these stories with our community. Our friend and physician wellness expert, Randall Levin, MD, F.A.C.E.P. shares our passion about making sure physicians and clinical leaders are well prepared to serve their patients. Dr. Levin and I are equally concerned about the current state of physician satisfaction, engagement and more importantly wellness. As these symptoms worsen due to reform and other contributing factors, it has become more apparent that we as an industry must make physician wellness a priority if we expect to see safety and quality improve. Dr. Levin practiced emergency medicine for 28 years, was a director of an emergency department, and is ACEP's physician wellness editor. Dr. Levin is an expert on physician wellness and we are lucky to have him as a contributor at the Coach+Leader. Please share his insights and solutions with your colleagues.

Brian Wong, MD

Provider/Physician Burnout: Taking The Battle to the Brain

Using Positive Psychology to Improve Engagment and, Ultimately, Patient Care

We all know something has to change. Debates on the direction of the healthcare system and competing approaches to patient care are flying fast and furious around us. Now is the time when we, the people who know patients best, need to be at the top of our game. This will allow us to be participating partners with our physician leaders in helping re-create the patient focus medical environment. A sense of well-being and decreasing burnout goes hand in hand with much needed change. Refocusing from provider survival mode to a role as a facilitator for patient outcomes can not easily occur without the element of wellness among providers and other healthcare team members. However, a recent Medscape survey indicates many of us are not at the top of our game.

of responding physicians reported they are burned out
A recent Medscape survey ( found 39.8% of all responding physicians were suffering from burnout. The numbers are even more daunting when drilling own in to specialties with Emergency Medicine and Critical Care physicians reporting burnout rates at or above 50%. All the specialities identified in the survey reported burnout levels exceeding 30%. How can we expect to be open to, or craft creative solutions and offer the very best care to others when we struggle so plainly to care for ourselves?

Burnout and Stress feed each other and we end up chasing out tails

A View of Burnout In Action

Here is a scenario many physicians, especially those in emergency medicine, can no doubt relate to:
It is an overwhelming busy day in the ED. All the rooms are filled with 10 (20, 30, etc) charts of patients who need to be placed into rooms. We are top-bedding admitted patients in our ED, because there are no vacant beds in-house. This top-bedding of patients in the ED, limits freeing beds up for our patients from the waiting room. The waiting room is filled to capacity and we are unable to divert (when an ED is overwhelmed you can divert any further ambulance patients to other open hospitals until the overcrowding resolves) our patients to another hospital due to protocol criteria (if all EDs are diverting then all EDs open up and cannot divert). The staff is overwhelmed and showing signs of stress, being short with colleagues and remaining disconnected from the patients being seen. We cannot "close" to take the pressure off and our lack of resources is causing what systems we had in place to unravel. The next moment I hear the EMS call-in box transmit information concerning a new patient being brought into the department. I think to myself, "Where will I put the patient? How can we safely care for yet another patient?".

I am not the only one wondering as I hear comments from both the medical and nursing staff.
  • "I cannot take on another patient, I am overwhelmed."
  • "I don't have anymore to give, and "they" (administration) can't expect us to stand for this."
  • "If I have to care for another patient, I am going to quit."
These statements, clear implications of stress and burnout, framed our mind state and how we perceived the patient the whole day.
This scenario, while extreme, is all too common and illustrates the real hurdles we need to overcome. Too often though, we focus on the external as the only way we could make this scenario different. "We just need more staff." "A few more rooms will solve our problems." While these changes might indeed help to improve things, what do we until we get additional staff or those new rooms? What do we do if those two changes are not enough to make a hectic day like this better? What do we do? We think differently.

Three Ways To Think Differently

Here are three positive psychology approaches that could help us change the scenario not only for ourselves, but our patients as well.

Be Present (Mindfulness)

The scenario above was already a hectic one when the EMS call came. My focus was on my "survival" and became distracted from the patient. When that happened, I was already jumping three steps ahead imagining negative and defeatist implications. The next time you feel the day spinning out of control, stop, and focus on that one patient in front of you or the one you will be seeing next. Give them your whole attention and effort. Reconnect to your empathy and compassion if you are sensing a disconnect.

Maintain Perspective

In the scenario above, I and all the staff around me were focused on what we were feeling and what we wanted. We had lost sight of the person and purpose we were there to serve. Stop, and review your posture, attitude, and approach. Now imagine you were the patient, scared and frustrated, about to be attended by someone in your current mindset. Putting our concerns in the broader context, can help us to connect with our patients and support mindfullness.

Be Flexible

Too often a response to stress is to default to the familiar. If your familiar is an environment where over 30% (or more) of your colleagues are burned out and disconnected, you may be defaulting to a position that will not provide you or your patient with positive returns. Stop, take a deep breath and ask yourself if you could approach your scenario differently. Take it one step further, ask someone else. Take it one more step, and ask someone you don't normally speak to. Taking a moment to open yourself up to alternative ideas or options, could result in a new successful path, providing you and your patients with a more positive experience.

These suggestions are not a panacea, nor are they the only options available to us. But I can truly state that my mindset was changed and my body language was more of an anticipatory "thank you" for the patient – thank you for allowing me to be there for you and use both my didactic medical knowledge and skills, along with my empathy and compassion. I could again focus on the patient (and not on how was I going to survive). It was not about having to be a "hero", but how to be a human being helping another human being.

I have adapted these ideas from concepts explored by Neil Farber, MD, PhD. His series on Positive Psychology offers an invaluable overview of more techniques and approaches to incorporate positive psychology into your practice and into your life. You can learn more about this series Burnout is real and it's ability to blind us from how we and why we practice medicine is powerful. Using a new way of thinking we can start to take those blinders off and smother the flames of burnout.

Dr. Randall Levin, MD, F.A.C.E.P.

Director for Physician Education - Medical Technology Management Institute, a continuing education division of Herzing University

  • ACEP Wellness Section Newsletter Editor
  • Practiced Emergency Medicine for 28 years
  • Past Director of Emergency Department - Aurora West Allis Medical Center
  • Past Member of Executive Committee - Aurora West Allis Medical Center

Tuesday, April 16, 2013

Tip 18: If doctors are afraid to speak up who will?

If doctors are afraid to speak up who will?

Bedside ImageIn her recent New Your Times article, "Afraid to Speak Up to Medical Power", Pauline Chen, MD discussed her personal experience in dealing with the all too common unsafe medical hierarchy that is endemic of our current healthcare culture. I'm glad to see such well respected physicians confronting these "old rules" that have such a profound impact on patient safety.

Dr. Chen shared how when the hospital where she worked, hired a "Rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital's then lackluster cancer center...", none of the incumbent medical staff felt comfortable challenging anything he said. Even the "Number 2" doctor on staff was afraid to throw in his two cents when he felt we was witnessing the wrong treatment for a patient. Long story short, due to an invisible, unspoken, fear driven medical hierarchy, two physicians who had more intimate knowledge of the patient than the new "superstar" kept quiet while suboptimal treatment was given causing a patient to die.

Dr. Chen cited a recent New England Journal of Medicine article, "Speaking Up — When Doctors Navigate Medical Hierarchy" by Ranjana Srivastava, F.R.A.C.P. which equally demonstrated this fear-based hierarchy through the eyes of a Medical Oncologist who was handed a patient from a resident. The patient was scheduled for surgery just a few hours after the physician made his courtesy call. He found the patient, "Scrunched up in bed, tossing and turning, his sheets tangled between his legs. He's pale and uncomfortable, licking his lips, his IV fluids having run out. My immediate impression is that he's dying. But I remind myself that he's scheduled for surgery." After conversing with the patient, the Oncologist felt sure that the patient wouldn't survive a surgery. But in this particular hierarchy, the surgeon was king and very few (if any) would question him. So when the surgeon showed up ready to proceed, the Oncologist figured he knew what he was doing, so he kept his mouth shut. And although the patient survived the surgery, he died shortly after. 

Afterward, (better late than never), he spoke to the surgeon about it, and the surgeon admitted that he would like to be told if he was perceived as inadvertently harming his patient. But the Oncologist couldn't have known that since the medical hierarchy has always been there... and has always been present in every hospital he'd worked in.

The two agreed to be more open and sharing in the future... just not soon enough for this patient.

You would think that physicians intervening with each other to help treat a patient, and especially to save a life, would be a given. Sadly it's the exception and medical hierarchies like these have proven to be a significant contributor to unsafe cultures. Almost all physician you and I know have experienced similar situations. I rarely meet a physician who doesn't have his or her own poignant story to tell me about an unsafe conversation with another doctor that led to suboptimal care.

It's the right time for Dr. Chen and Dr. Srivastava to be voicing their concern on the issue as many suggest the symptoms are getting worse. When I began writing my book, "Heroes Need Not Apply", two years ago, it was clear that this challenge was becoming more pronounced, as healthcare reform places greater emphasis on providers working as integrated teams to improve quality, create efficiencies and reduce cost. Understanding that the severity and frequency of these unsafe exchanges has nowhere to go but up, my book takes a close look at the key factors that produce unsafe medical hierarchies and what we as medical community must do about it. Now that the book is set to be published this Summer, I'm hoping that this story and the leadership of physicians like Dr. Chen and Dr. Srivastava, can offer a new template for how we physicians interact, as there is no room for these medical hierarchies in these new care models.

Like most cultural challenges we face, medical hierarchies and the "old rules" that follow are steeped in medical training and can't be resolved with a checklist or confronted with punitive approaches. If we physicians are to prevent unsafe conversations, we're going to need to replace the template for how we interact. Consider our current context, a template for interaction that celebrates individual expertise, credentials and honors. In other words, a culture that rewards and recognizes individual heroic effort with little emphasis on peer coaching, physician collaboration,and clinical teamwork.

18 Tip: How to defuse a medical hierarchy in 5 seconds or less.

Medical hierarchies often create conditions that allow extraordinary power to be given to extraordinary physicians. These physicians are highly accomplished, have numerous credits to their name, and get excellent results. Physicians like Dr. Chen and myself operate within this hierarchical context, assuming that because they are the best at what they do, they must know what's best for the patient. This is the most costly (and incorrect) assumption we make,and it's ultimately shortchanging our patients. As we formulate assumptions like these, our "superstar physicians" become dangerously unapproachable, resulting in a system with fewer checks and balances. Simply said, we begin to rely too heavily on the smartest person in the room and minimize collaboration, which hinders patent-centered exchanges.

Keep in mind that incompetence is rarely the issue, as in most cases, our "superstar" specialist in question is often administering the right treatment for the condition. However, in many of the cases I've consulted on, similar to that of Dr. Chen and Dr. Srivastava, the lead physicians often become too focused on treating the disease without considering the human factors that matter most to the patient and influence outcomes. These physicians report getting fixated on the medical response while minimizing the concerns of the patient and/or another physician.

So what is the answer to defusing medical hierarchy? And how do we create a zone of safety and improve physician collaboration?The answer to this safety challenge is simpler than the average checklist and resides with just one question: "What matters most to the patient?"

I can tell you from the experience of working with hundreds of physicians, this question is 99 percent effective at disabling and preventing harmful conversations. Why is it such an effective coaching tool? Patient-centered questions like this help physicians navigate the power differential by putting the focus on patient concerns and helping the team review the medical response in a more thoughtful way. It sends the signal to all those "superstars" out there that your not competing for the smartest guy in the room award or telling the other guy, "I know something you don't".
We don't need hero physicians. We need team players and coaches.

Email me or share your thoughts on our Facebook page.

Brian WongDr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Brian WongCheck out the new video interview with Brian Wong, M.D.
to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

Exclusive Q&A interview with Brian Wong, MD

Join us for an exclusive Q&A interview
Brian Wongwith Brian Wong, MD: Author of the soon to be released book Heroes Need Not Apply

WHEN: April 24th, 2013
1:00PM EST (10:00AM PST)
We'll keep it short for you, 20 minutes.

Brian Wong, M.D.WHAT: Dr. Brian Wong will be answering your questions regarding specific accountability challenges at your hospital on a conference call interview moderated by Sierra Weese of Innovative Healthcare Speakers

Please email your question to Sierra by April 22nd, and Dr. Wong will respond to as many as possible during our interview. Join us for a rare opportunity to pick the brain of one of the country's foremost healthcare culture experts on April 24th.

HOW: Conference call in info -- 1 (877) 365-2980
Participant Code: 1332 (A reminder email will be sent prior to the interview.)
There is no charge to connect to this call. Call-in space is limited.

Everyone in healthcare knows the lack of accountability negatively impacts care, and when accountability improves throughout your organization, care improves. What healthcare leaders didn't know until now, was how to improve accountability and why it is so critically linked to improving patient care. Knowing that every hospital has its own specific accountability challenges, Innovative Healthcare Speakers would like to give you the opportunity to get some of your challenges addressed.

Learn more about Brian Wong, MD
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Speaking Engagements:
Innovative Healthcare Speakers brings you the opportunity to schedule your next speaking engagement, keynote, workshop or retreat with Brian Wong, M.D., author of his soon-to-be published book by Second River Healthcare Press, Heroes Need Not Apply: How to build a patient accountable culture without putting more on your plate.

Dr. Wong's interactive speaking programs bring the book's key tools and concepts directly to his audiences, where they experience the process of taking the first steps toward having a patient accountable culture in their organizations.

As a highly respected speaker and consultant nationwide, the compelling subject matter of his soon-to-release book is leading to increased demand on the speaker/facilitator circuit. Contact Sierra Weese to book him for your upcoming meeting or event.

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