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A National Perspective to Address and/or Prevent Provider Burnout
Mickey Trockel, MD, PhD, Director of Scholarship and Health Promotion for the Stanford School of Medicine WellMD Center, discusses healthcare provider burnout, his experience as a researcher at Stanford in this field and what organizations and providers can do to address and/or prevent burnout.
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Learn more about Mickey Trockel, MD
Mickey Trockel, MD, PhD
Mickey Trockel, MD, PhD is the Director of Scholarship and Health Promotion for the Stanford School of Medicine WellMD Center. He noticed early in his training how physicians’ propensity to defer their own wellbeing to serve others interacts with a culture of medical practice that can impede self-care. Observing this, he wants to equip health care leaders and educators with the skills they need to shift cultural norms in medicine towards a compassion driven culture that promotes physician wellbeing and associated clinical effectiveness. He and his colleagues also help individual physicians with strategies for their own wellbeing and related professional performance.Learn more about Mickey Trockel, MD
Transcription:
Melanie Cole (Melanie): Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episode’s posttest.
Today we’re talking about healthcare provider burnout on the national level. My guest is Dr. Mickey Trockel, he’s the Director of Scholarship and Health Promotion for the Stanford School of Medicine Well MD Center. Dr. Trockel, with the ever increasing need for healthcare providers, as people are living longer, what are you seeing as far as provider satisfaction with the healthcare industry?
Dr. Mickey Trockel (Guest): Well it’s mixed. I think physicians still, most of us, derive a great deal of meaning in our work. There are some things that have made provider satisfaction more difficult, as I think you’re aware. The advent of the electronic health record, while in theory was billed as something that could streamline health care and has the potential for making improvements in healthcare was implemented in a way that slid more work to physicians, things that could perhaps more easily be done by members of the healthcare team that could be working to the top of their license to help out in ways that could make patient care much more efficient. Those practices, those duties were falling on the shoulders of physicians in ways that increased their workload, decreased their control in their workspace and as we implemented health records at the same time that more and more physicians are in employed models, rather than independent practice models, physician satisfaction clearly trailed off. We know from Tait Shanafelt and his colleague’s research at Mayo Clinic in a national survey that between 2011 and 2014 physician burnout and physician satisfaction both got worse during that time and the difference is larger between physicians and the general population across that timespan as well.
Melanie: And tell us about your experience as a researcher at Stanford in this field. What are you doing?
Dr. Trockel: Well one of the things that will be published very soon, I think I can talk about this now because it’s been accepted and so it’s in press so it’s okay for me to talk about some of the details, is a study on physician turnover. In 2013, we followed physicians who were burnt out and then physicians who were not burnt out and we were able to determine who left their organization during two years, so by 2015 and what we found is that among those who are burnt out 21% had left the institution, where as among those who were not burnt out, only 10% had left the institution. So that’s attributable risk of 11%. In other words, among physicians who were burnt out, which is a fairly large chunk, at most institutions that’s somewhere between 30% and 50%, among that group, 11% would be leaving the institution within two years for reasons attributable to their burnout. Now that turns out to be expensive. We asked our chief financial officer how much that costs and she gave us the figures and we then did the math to show how much burnout was costing just in terms of turnover that was attributable to burnout and that was many millions and that was an important piece of research for us to garner support by making the business case for addressing physician wellness.
Melanie: That’s so interesting. Now when people are looking at – we’ve talked about it a little bit and we’ll get into it more with the reasons for some of the burnout, but sometimes it’s hard to recognize. Doctor, how do you measure and respond and recognize the burnout. I mean whether it’s depersonalization or negative attitude of the provider, exhaustion, lack of empathy, any of these things, how is that recognized and measured?
Dr. Trockel: Well we measure it by implementing a standardized validated measure and there are a few that are available. At Carle they used Oldenburg Scale, which was developed in Europe. Maslach Burnout Inventory has been available at a cost for a long time. We wanted to develop a way of measurement – a way of measuring burnout that was sensitive to change and so we developed our own measure that uses ten items all answered on a Likert scale to assess work exhaustion, which is equivalent to emotional exhaustion in the Maslach scale and to measure interpersonal disengagement, which is the part of depersonalization we felt was most relevant to physicians and then we put a two week window on it, meaning that those questions are answered relative to physician’s experience within the last two weeks and that allows us to have a measure that’s more sensitive to change so that we can test physicians before and after an intervention and see if we’re moving the needle, but the most common way of recognizing burnout currently is through these self report instruments and that’s what we’re relying on predominately as well. Certainly there is something to be said for recognizing the signs of burnout in a colleague and offering to help or offering to direct the individual who’s suffering from burnout to resources to where they can get help.
Melanie: Dr. Trockel, are we discussing only physicians, or is this something on the broad spectrum of healthcare providers? For example, if it is stress on the nursing staff or other staff members who might not be somebody that gets looked at or tries out these particular scales that you’re discussing. Is that also a part of this picture?
Dr. Trockel: Absolutely, and at least in our children’s system, we actually have assessed burnout and professional fulfillment and the determinacy of both of those in every employee of the entire institution. Physicians have unique stressors. We think that dealing with physician burnout and on the opposite end of that spectrum on – helping with professional fulfillment, it’s best to address physicians specifically and to target interventions to that group specifically because they have unique needs, but the same could be said for every other group. While we think a one sized fits all program ultimately won’t be most effective. We absolutely believe it’s important to address wellness for every employee group and our wellness survey for all of our Lucille Children, Lucille Packard Children’s Hospital, Hospital and Clinic System that included everybody in every aspect of the organization, helps us with a first step towards that.
Melanie: So what are doing to respond to some of this, and as doctors have that onerous maintenance of certification requirements and the clerical burden, and all of these things we’ve been discussing, how do you respond to it? What are you doing, things like workflow design? What organizations and providers can do?
Dr. Trockel: Absolutely, and I was hoping we’d get to this. This is the most important piece for me. We think of the solution in terms of three buckets and we have a short article that we published in the New England Journal of Medicine’s catalyst forum that outlines these three buckets and describes them. One is efficiency of practice and that’s what you’re referring to and the solutions for that are developing collaborative, creative ways of adapting to change, helping physicians identify the specific things that are causing distress and the empowering them to be part of teams that develop and implement solutions and then evaluate the impact of those solutions in terms of how much they effect things like physician burnout and then repeating that experiment over and over again constantly aiming for improving. That process was written about by Tait Shanafelt and Stephen Swensen from the Mayo Clinic when Tait was still at the Mayo Clinic. It’s called the listen, act, develop model. It’s leadership 101 principals but when systematically applied, do help individual organizations improve their workflow, improve their communication and improve employee satisfaction, engagement, and reduced burnout. So there’s that piece. There are of course targeted things like providing electronic health record coaching to individuals who are outliers who are spending way more time than average to complete their electronic health record work. Often offering coaching to those individuals can help them drastically reduce the amount of time that they’re engaged in that kind of work and go to home earlier and so we offer that kind of coaching at Stanford as well. Then there’s of course the individual physician factors. There’s the personal resilience factors. The personal resilience strategy that’s probably most evidenced based at this point is mindfulness practice. We know that not everybody is open to practicing mindfulness meditation, but those that are benefit greatly. Two randomized trials demonstrate the efficacy of mindfulness practice in physicians specifically. In one study, physicians who were randomized to the mindfulness practice, had not only improvement in psychological measures but a reduction in resting heart rate that was averaging at 75, went down to 69 and that physiologic improvement was maintained one year later and there were many others of course in the individual resilience domain. We could talk about that for hours, but then there’s a place in the middle. There’s an organizational factor, but it’s a factor each one of us in an organization contributes to and that’s our culture of wellness, it’s how we feel about, think about, and treat each other. So while at Stanford we’re offering efficiency of practice solutions and we’re doing what we can to encourage and offer and facilitate personal resilience development, this culture of wellness piece is where I’m most excited about innovative things that we’re trying and it’s things that are like offering peer support programs. It’s capitalizing on natural leaders within work groups to encourage each other and physician work groups to practice things that promote a culture of wellness like gratitude exercises and values alignment exercises to improve the sense of agreement between one’s own values and the values of the organization as being compatible and we’re just now developing and testing those and so I can’t say a whole lot about how well they’re working because we’re just getting starting, but that culture of wellness to me where we’re moving the needle and how we think about, feel about, and treat each other at work is something I’m particularly excited about as part of the equation to solving this problem. One related construct to this is psychological safety and that piece actually has been fairly well researched. Amy Edmundson demonstrated in her work at Harvard, that work groups who had things like inclusive leadership style, which is an aspect of psychological safety were more engaged in quality improvement, and that’s one piece that already has been demonstrated so we’re trying to move the needle on all three domains, efficiency of practice, culture of wellness, and personal resilience.
Melanie: Wow, that’s so interesting, Dr. Trockel, and I think you really hit the nail on the head with how people treat each other at work and I think some of the information you’ve been discussing really can go through all aspects of every different kind of employment. As you wrap up for us, what do you want other providers to know. If they’re feeling burned out, how they can find joy in their practice again and what you’d like them to know about seeking that help or for one of their colleagues and really just wrap it up for us.
Dr. Trockel: I think the one individual level predictor of burnout that would be most important for me to mention to anybody who is in healthcare suffering from these kinds of distress experiences is self compassion. We have a unique take on self compassion that we call self valuation. It involves appropriate prioritization of self care and being able to recognize errors as something that while painful, they’re something to learn from rather than having shame and blame and a harsh internal response to errors be the first reaction to when something goes wrong. Physicians who are able to be as compassionate with themselves as they might be with a colleague in this way in prioritizing one’s own well being in these ways are much less likely to suffer from burnout, and if they’re already suffering from burnout, there’s a good chance that there’s something in that realm of self compassion or what we’re calling self valuation that is likely to be at least part of the problem, and therefore also part of the solution.
Melanie: That’s great information. Thank you so much, Dr. Trockel, for joining us today and sharing your expertise and your research in this area. It was very interesting segment. Thank you again. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored education activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Melanie): Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episode’s posttest.
Today we’re talking about healthcare provider burnout on the national level. My guest is Dr. Mickey Trockel, he’s the Director of Scholarship and Health Promotion for the Stanford School of Medicine Well MD Center. Dr. Trockel, with the ever increasing need for healthcare providers, as people are living longer, what are you seeing as far as provider satisfaction with the healthcare industry?
Dr. Mickey Trockel (Guest): Well it’s mixed. I think physicians still, most of us, derive a great deal of meaning in our work. There are some things that have made provider satisfaction more difficult, as I think you’re aware. The advent of the electronic health record, while in theory was billed as something that could streamline health care and has the potential for making improvements in healthcare was implemented in a way that slid more work to physicians, things that could perhaps more easily be done by members of the healthcare team that could be working to the top of their license to help out in ways that could make patient care much more efficient. Those practices, those duties were falling on the shoulders of physicians in ways that increased their workload, decreased their control in their workspace and as we implemented health records at the same time that more and more physicians are in employed models, rather than independent practice models, physician satisfaction clearly trailed off. We know from Tait Shanafelt and his colleague’s research at Mayo Clinic in a national survey that between 2011 and 2014 physician burnout and physician satisfaction both got worse during that time and the difference is larger between physicians and the general population across that timespan as well.
Melanie: And tell us about your experience as a researcher at Stanford in this field. What are you doing?
Dr. Trockel: Well one of the things that will be published very soon, I think I can talk about this now because it’s been accepted and so it’s in press so it’s okay for me to talk about some of the details, is a study on physician turnover. In 2013, we followed physicians who were burnt out and then physicians who were not burnt out and we were able to determine who left their organization during two years, so by 2015 and what we found is that among those who are burnt out 21% had left the institution, where as among those who were not burnt out, only 10% had left the institution. So that’s attributable risk of 11%. In other words, among physicians who were burnt out, which is a fairly large chunk, at most institutions that’s somewhere between 30% and 50%, among that group, 11% would be leaving the institution within two years for reasons attributable to their burnout. Now that turns out to be expensive. We asked our chief financial officer how much that costs and she gave us the figures and we then did the math to show how much burnout was costing just in terms of turnover that was attributable to burnout and that was many millions and that was an important piece of research for us to garner support by making the business case for addressing physician wellness.
Melanie: That’s so interesting. Now when people are looking at – we’ve talked about it a little bit and we’ll get into it more with the reasons for some of the burnout, but sometimes it’s hard to recognize. Doctor, how do you measure and respond and recognize the burnout. I mean whether it’s depersonalization or negative attitude of the provider, exhaustion, lack of empathy, any of these things, how is that recognized and measured?
Dr. Trockel: Well we measure it by implementing a standardized validated measure and there are a few that are available. At Carle they used Oldenburg Scale, which was developed in Europe. Maslach Burnout Inventory has been available at a cost for a long time. We wanted to develop a way of measurement – a way of measuring burnout that was sensitive to change and so we developed our own measure that uses ten items all answered on a Likert scale to assess work exhaustion, which is equivalent to emotional exhaustion in the Maslach scale and to measure interpersonal disengagement, which is the part of depersonalization we felt was most relevant to physicians and then we put a two week window on it, meaning that those questions are answered relative to physician’s experience within the last two weeks and that allows us to have a measure that’s more sensitive to change so that we can test physicians before and after an intervention and see if we’re moving the needle, but the most common way of recognizing burnout currently is through these self report instruments and that’s what we’re relying on predominately as well. Certainly there is something to be said for recognizing the signs of burnout in a colleague and offering to help or offering to direct the individual who’s suffering from burnout to resources to where they can get help.
Melanie: Dr. Trockel, are we discussing only physicians, or is this something on the broad spectrum of healthcare providers? For example, if it is stress on the nursing staff or other staff members who might not be somebody that gets looked at or tries out these particular scales that you’re discussing. Is that also a part of this picture?
Dr. Trockel: Absolutely, and at least in our children’s system, we actually have assessed burnout and professional fulfillment and the determinacy of both of those in every employee of the entire institution. Physicians have unique stressors. We think that dealing with physician burnout and on the opposite end of that spectrum on – helping with professional fulfillment, it’s best to address physicians specifically and to target interventions to that group specifically because they have unique needs, but the same could be said for every other group. While we think a one sized fits all program ultimately won’t be most effective. We absolutely believe it’s important to address wellness for every employee group and our wellness survey for all of our Lucille Children, Lucille Packard Children’s Hospital, Hospital and Clinic System that included everybody in every aspect of the organization, helps us with a first step towards that.
Melanie: So what are doing to respond to some of this, and as doctors have that onerous maintenance of certification requirements and the clerical burden, and all of these things we’ve been discussing, how do you respond to it? What are you doing, things like workflow design? What organizations and providers can do?
Dr. Trockel: Absolutely, and I was hoping we’d get to this. This is the most important piece for me. We think of the solution in terms of three buckets and we have a short article that we published in the New England Journal of Medicine’s catalyst forum that outlines these three buckets and describes them. One is efficiency of practice and that’s what you’re referring to and the solutions for that are developing collaborative, creative ways of adapting to change, helping physicians identify the specific things that are causing distress and the empowering them to be part of teams that develop and implement solutions and then evaluate the impact of those solutions in terms of how much they effect things like physician burnout and then repeating that experiment over and over again constantly aiming for improving. That process was written about by Tait Shanafelt and Stephen Swensen from the Mayo Clinic when Tait was still at the Mayo Clinic. It’s called the listen, act, develop model. It’s leadership 101 principals but when systematically applied, do help individual organizations improve their workflow, improve their communication and improve employee satisfaction, engagement, and reduced burnout. So there’s that piece. There are of course targeted things like providing electronic health record coaching to individuals who are outliers who are spending way more time than average to complete their electronic health record work. Often offering coaching to those individuals can help them drastically reduce the amount of time that they’re engaged in that kind of work and go to home earlier and so we offer that kind of coaching at Stanford as well. Then there’s of course the individual physician factors. There’s the personal resilience factors. The personal resilience strategy that’s probably most evidenced based at this point is mindfulness practice. We know that not everybody is open to practicing mindfulness meditation, but those that are benefit greatly. Two randomized trials demonstrate the efficacy of mindfulness practice in physicians specifically. In one study, physicians who were randomized to the mindfulness practice, had not only improvement in psychological measures but a reduction in resting heart rate that was averaging at 75, went down to 69 and that physiologic improvement was maintained one year later and there were many others of course in the individual resilience domain. We could talk about that for hours, but then there’s a place in the middle. There’s an organizational factor, but it’s a factor each one of us in an organization contributes to and that’s our culture of wellness, it’s how we feel about, think about, and treat each other. So while at Stanford we’re offering efficiency of practice solutions and we’re doing what we can to encourage and offer and facilitate personal resilience development, this culture of wellness piece is where I’m most excited about innovative things that we’re trying and it’s things that are like offering peer support programs. It’s capitalizing on natural leaders within work groups to encourage each other and physician work groups to practice things that promote a culture of wellness like gratitude exercises and values alignment exercises to improve the sense of agreement between one’s own values and the values of the organization as being compatible and we’re just now developing and testing those and so I can’t say a whole lot about how well they’re working because we’re just getting starting, but that culture of wellness to me where we’re moving the needle and how we think about, feel about, and treat each other at work is something I’m particularly excited about as part of the equation to solving this problem. One related construct to this is psychological safety and that piece actually has been fairly well researched. Amy Edmundson demonstrated in her work at Harvard, that work groups who had things like inclusive leadership style, which is an aspect of psychological safety were more engaged in quality improvement, and that’s one piece that already has been demonstrated so we’re trying to move the needle on all three domains, efficiency of practice, culture of wellness, and personal resilience.
Melanie: Wow, that’s so interesting, Dr. Trockel, and I think you really hit the nail on the head with how people treat each other at work and I think some of the information you’ve been discussing really can go through all aspects of every different kind of employment. As you wrap up for us, what do you want other providers to know. If they’re feeling burned out, how they can find joy in their practice again and what you’d like them to know about seeking that help or for one of their colleagues and really just wrap it up for us.
Dr. Trockel: I think the one individual level predictor of burnout that would be most important for me to mention to anybody who is in healthcare suffering from these kinds of distress experiences is self compassion. We have a unique take on self compassion that we call self valuation. It involves appropriate prioritization of self care and being able to recognize errors as something that while painful, they’re something to learn from rather than having shame and blame and a harsh internal response to errors be the first reaction to when something goes wrong. Physicians who are able to be as compassionate with themselves as they might be with a colleague in this way in prioritizing one’s own well being in these ways are much less likely to suffer from burnout, and if they’re already suffering from burnout, there’s a good chance that there’s something in that realm of self compassion or what we’re calling self valuation that is likely to be at least part of the problem, and therefore also part of the solution.
Melanie: That’s great information. Thank you so much, Dr. Trockel, for joining us today and sharing your expertise and your research in this area. It was very interesting segment. Thank you again. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored education activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.