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Roxanna Gapstur PhD, RN (Host):  Today, we’re going to explore a tough topic, burnout. With stress and anxiety at an all time high across the country, we find ourselves looking for ways to maintain normalcy and reduce stress. But the truth is, avoiding burnout takes discipline. Leaders can take purposeful steps to lead their teams to higher levels of engagement and reduce the risk of burnout. We’ll cover three themes in our conversation today. First, the impact of burnout on physicians and healthcare workers. Second, the unintended consequences of burnout on an organization’s brand and consumer experience and finally, we’ll share some steps that leaders can take to care for and protect their team so they can deliver the best value to consumers. Joining me today, is Dr. Ridge Salter. He’s the Medical Director for Quality and Innovation at WellSpan and Chair of our Wellbeing Council. He’s also a practicing Family Medicine physician in York, Pennsylvania. Ridge, thanks for joining me today.

Ridge Salter, MD (Guest):  Thanks for having me Roxanna. I’m excited to be here to discuss this important issue.

Host:  Ridge, you and I know the statistics all too well. Burnout across the country, pick any industry, is far too common. And healthcare, we know it’s been rising at alarming rates. In fact, the Advisory Board reports that as many as 60% of physicians report feelings of burnout. High rates of work-related stress among healthcare employees can lead to lower levels of staff engagement and it correlates with lower productivity and patient experience. We can safely assume that COVID-19 has not helped this situation at all. And that the duality of remote working while caring for families and for some, the stress of facing racial injustice and inequities head on has added an incredible amount of stress to our daily lives. This only increases the likelihood of burnout. So, Ridge, help us understand what burnout is and what it looks like at the individual level.

Dr. Salter:  Burnout can be defined in many different ways, but one way is that it’s a long-term reaction to work stress resulting in at least one of three of the following. Emotional exhaustion, depersonalization and a lack of personal accomplishment. For health caring professionals, there are many different stressors in healthcare to nobody’s individual fault. But it has produced a situation where highly motivated and mission driven professionals are working in unhealthy environments in which they feel unable to succeed. And this was all occurring before the stressors of the COVID pandemic and the recent social unrest in response to racial injustices. So, now we’re experiencing stress on top of stress.

But what does it look like in an individual? Well it could look like me. Or one of my colleagues who have just lost the joy of the greatest profession in the world which is caring for people. It could be manifested as poor quality outcomes or an increase in medical error rates. So, you might see it as an SRS, a safety event. It could be seen in decreased patient experience or decreased health caring professional engagement. So, you might see it as a CRS or a consumer related complaint. You might see it as decreased health outcomes and health risks in our health caring professionals like increased mental health issues, substance abuse, dysfunctional relationships. But you might see it as different behaviors like public venting, disruption in our offices or operating rooms. You might see decrease in hours, changing jobs, retiring early or even leaving the profession. And unfortunately, sometimes it’s seen as physician suicide which occurs approximately one time a day in America.

Host:  Ridge, I can feel your passion for the subject. It hits close to home doesn’t it?

Dr. Salter:  Yeah, I think the thing that pains me the most is just watching my colleagues struggle. Any number of factors that lead to their burnout. It could be issues with the HER, with insurance, with regulations, a negative patient experience comment, feeling under appreciated by their employer, malpractice suit, an unexpected patient death. And of these and sometimes a number of these contributes to burnout and robs them of the joy of their profession. But for me, it’s not uncommon as someone who is interested in trying to address burnout, is that it comes through a journey to where I am today through my own burnout.

So, about 13 plus years in a practice, I was running full steam ahead, seeing patients roughly every 15 minutes but I was engaged. I wanted not only what’s best for my patients but what’s best for the healthcare system. I was President of our WellSpan Medical Group Board but trying to be everything. Trying to be a great father, husband, coach and I would go home after a long day, have a quick family dinner and off we were to basketball practice, then finally at the end of the day, get home and settle in probably after 9 o’clock, but staring at two plus more hours of work to finish up tasks and notes and result review. What we call pajama time.

And I got a task that asked me to comment on the results of a test ordered by a fellow physician and for some reason, I just lost it. I slammed my laptop. I turned to my 17 year old son Nick who was about ready to go to college wanting to pursue a career in medicine and I said Nick, don’t go into medicine. The work is endless. You don’t get respect from patients, from colleagues, and God forbid if you do go into medicine, don’t go into Primary Care. Because the bleep rolls downhill to them. And there was silence. And I knew at that point, I was in a bad place. I was burnt out. And I needed a change. But lucky for me, this role became available and as Medical Director with the medical group, I now am able to work with my colleagues. I’m able to meet regularly and develop our site directors to become leaders in their own practices. And I’ve taken on a role in our Wellbeing Council as now the Chair. So, now, I get to focus my efforts on improving the wellbeing of my colleagues.

Host:  Ridge, thanks for sharing that story. That’s a really powerful example of how burnout can impact an individual. Appreciate you sharing that. You know I began my own career as a nurse caring for patients in the ICU and when I think back on that time, I really remember the stress of the situation. It was a nursing shortage especially in areas where specialty nurses were needed, and specific skills were required. And I spent long, long days in the ICU, 12 to 16 hours with really basically a Mountain Dew and myself and my patient. And you can only do that for so long before you start to think about not only just the stress of doing something else, thinking this just can’t be all that there is. As much as I loved caring for my patients and spending time with their families as well. It became too much after a time.

I hear what you’re saying about burnout and I have felt it myself as well in my clinical practice.

Dr. Salter:  So, Roxanna, what did you learn from that experience?

Host:  You know one of the things that it taught me Ridge, is that instead of managing my time, I really needed to manage my energy. And maybe you were referring to that a little bit in your statements as well. There are a lot of things that bring me passion related to healthcare and related to my work. And I think part of the understanding of yourself as a person is to understand what those things are that really bring you passion and bring you joy. And to work towards identifying how you can have more of that either in your practice or with your colleagues and less of the things that being you stress. And it certainly doesn’t mean that every single day is an absolute joy and you never feel stressed at work because we all know that that’s not realistic. Each day is actually pretty different. It’s pretty different for our clinical care teams and it’s pretty different actually in administrative roles as well.

As you know, you might come to work in the morning thinking that you have eight hours all planned out and you might spend your time in the COVID-19 command center instead. So, we do have to be flexible in healthcare. But this idea of managing my energy has been really helpful to me over the last ten or fifteen years and I’ve spent quite a bit of time thinking through that. I know myself pretty well now and just even taking ten minutes every couple of hours with some mindfulness tapes or mindfulness breathing has really helped me. So, I just think you kind of have to know yourself and what can help relieve your own stress. And that is a big part of understanding what you can do for yourself and also for the teams around you to help with burnout.

Dr. Salter:  Yeah finding ways to fuel your tank. Right?

Host:  Yes. Absolutely. Yeah. It’s why we really want to be purposeful about addressing burnout within our own organization. So, I’m wondering if you could talk to us a little bit about that Ridge?

Dr. Salter:  Yeah. Burnout’s been studied pretty extensively and there’s at least six areas where you could – you focus on the main causes of physician and APP burnout. The first is work overload. Sometimes there’s just too much to do and not enough time to do it. But the other factors fall under the following topics. Inefficiencies with undue clerical burden. Loss of control. Work life imbalance. Loss of meaning in the work and then conflicting values with how you want to deliver the care. So, we can address these systems as an issue.

The first thing we have to do is make sure that our physicians and APPs are supported, and they have a voice and we have a pretty good governance structure to allow that. We have regular rounding of our leaders including that with our site directors and we even encourage our site directors to round regularly with their physicians and APPs so they can celebrate the wins. And hear what they need to be addressed. But secondly, we have a number of different recognition and appreciation programs that we are developing so that we can take time to address what needs to be celebrated. We listen to our physicians and APPs via surveys and what they’re looking for in regards to the wellbeing and how we can deliver that to them in the form of regular conference. We make regular resources available to them for self-care. We work on our care teams. We try to make our care teams improve so they are working to the top of license. We redirect our low acuity visits to low cost solutions, and we extend our clinical reach in a safe manner through other options which are now becoming pretty good at like our Telehealth options.

Host:  That’s great. I know Ridge that you’re leading some work in the medical group that has shown really promising results for reducing burnout. Some of it is related to the Joy in Work framework from IHI, the Institute for Healthcare Improvement. Can you share some of that with us?

Dr. Salter:  Yeah, we’ve been fortunate to do a number of different pilots through this IHI framework or what’s call Joy in Work and basically, what we’re doing is we ask our office to identify two things. What are the pebbles in your shoes and what brings you joy regularly in your work? And then from there, we ask them to focus on one project in either one of those arenas and we do a typical plan, do, study, act cycle where we try to study and improve upon either the pebble or the joy. And we’ve been through 53 practices so far and we’ve had some great results.

Host:  Great. Would you share some of the results with us?

Dr. Salter:  Yeah. Our most recent cohort was 23 practices and we studied it from last September to this January. And through their work, we were able to measure scores before and after the study period and we showed a 10% decrease in emotional exhaustion scores, and a 19% improvement in the care team’s burnout rate. So, we were pretty pleased that this intervention could make a difference.

Host:  That’s great. I really like that concept of Joy in Work and recognition. In fact, over the last year, one of the things we started was creating new opportunities for all of our leaders to recognize their team members and for team members to recognize their peers. I don’t know if people remember back but we did something called Thirty Days of Fun last August and it was amazing how much engagement we had across our organization. Even the small ways of showing appreciation for each and every team member can make a difference.

Ridge, how else do you think individuals can reduce those feeling of burnout?

Dr. Salter:  Well, the first thing they can do is to invest in self-care. And this is an important topic. And I want to get across the point that self-care is not selfish. In fact, self-care is taking time to invest in yourself so you can be the best that you can be to take care of your patients, to be a great colleague, to be a great spouse, parent, friend and if we do that, we’re going to be better at what we do. And there’s plenty of data out there that shows that doing that makes a difference. There’s data that meditation, exercise, social connections, spiritual connections, narrative medicine, the list goes on. All of these have been shown in one way or another to reduce the symptoms of burnout. But I’d be remiss if we just focused on what individuals can do for their own burnout. It’s as or maybe even more important that our health systems continue to improve in areas of efficiency of practice, like our EHR and our care teams, make sure they are optimized and working to the top of their license and develop a culture of wellness, fair compensation, appreciation, regular recognition and then it’s incumbent upon our physicians and APPs to engage in these initiatives that are being offered by the system. Work with your leaders. Become part of the solution.

Host:  That’s really great advice Ridge. It’s a topic that’s relevant to so many industries and especially to healthcare. So a good reminder of how we can participate, engage and help manage these stressors. Let’s recap our exploration of burnout today. Understand what burnout looks like for your team by asking through surveys or focus groups. Check in regularly with your team especially during times of vulnerability and stress. Develop conversation guides that can help leaders walk through challenging conversations. And never forget to offer behavioral health resources to your teams or the Employee Assistance Program if one is available where you work. Most importantly, as leaders, we should model what we ask of others. Thanks for joining me today Ridge. I really appreciated you being here to talk about such an important topic.

Dr. Salter:  Thanks for having me Roxanna. I agree, it’s incredibly important but we can do this. We can make it better for our health caring professionals.

Host:  Absolutely we can. That’s all the time we have for today. We hope you’ll join us for the next episode of Inspiring Health.