Healing the Healers
Until recently, physician burnout was something of a taboo topic in medical circles, but the problem has become so severe that it is now at the center of a national conversation, and Elizabeth Lawrence, MD, thinks UNM should have a voice in it.
Burnout is a multifaceted syndrome characterized by a high degree of emotional exhaustion, depersonalization (cynicism), and a low sense of personal accomplishment at work. It now affects more than half of all practicing physicians.
The consequences are serious for everyone, says Lawrence, affecting the quality and cost of health care and the nation’s ability to treat an increasingly sick population. Lawrence, who was chief resident in Internal Medicine at UNM in the 1990s, returned to the faculty in 2015 after a decade in private practice specifically to focus on physician wellness and preventing provider burnout.
“In my private practice I cared for a large number of health care providers, and was very struck by the impact that our work has on individual health,” she says. “Also, I myself burned out, having found that it was very difficult to run a private practice, handling everything from clogged toilets to employee hiring, while raising kids and taking care of dying parents.”
She took time off and dove into the research, coming across a growing body of literature in a growing field. When an opportunity arose in the area of undergraduate medical education at UNM, Lawrence became the director of the Office of Physician and Student Wellness.
“I always felt you couldn’t send medical students into an environment with burned-out residents or faculty and expect them to learn good self-care,” she says. Accordingly, the program includes initiatives at all levels. At its heart is a four-year curriculum that teaches skills ranging from time management to health coaching and self-care (yoga, mindfulness, narrative reflection) to the de-stigmatization of seeking help.
“There is a national call to pay attention to this issue,” Lawrence notes, because burnout raises the cost of care and increases the likelihood of physician error and the ordering of unnecessary tests. Patients are also impacted by disruptive or rude interactions with burned-out physicians.
The toll on health care workers themselves is especially alarming: Nearly a quarter of ICU nurses tested positive for post-traumatic stress in one study, while physician experience high rates of depression (39 percent) and suicide rates are double that of the general population.
One major reason that burnout is rising among physicians – up from 44 percent in 2011 to 54 percent today – comes down to recent changes in the nation’s health care system, Lawrence says.
The growing clerical burden of electronic recordkeeping and the loss of autonomy that results from new regulatory requirements are draining physicians of their main source of meaning at work, interacting with patients. According to a recent study, only 27 percent of physicians’ work time is spent in direct contact with patients. The rest is spent on paperwork, “which isn’t meaningful to anybody,” she notes.
With patients developing more severe illnesses at younger ages, such that doctors must treat as outpatient those who would formerly have gone to the hospital, “it’s recognized that we will not have an adequate work force to provide for patients” if burnout is not addressed, Lawrence says.
“Major medical associations are focusing on it, and it is getting a lot of attention at all levels of training.”
There is a rising call to add a fourth aim – provider well-being – to the so-called triple aims of health care: providing high-quality, evidence-based care at optimal cost. “We need to teach our students not to make the same mistakes that we have,” Lawrence says.
Part of that is addressing what she calls the culture of perfectionism: “I’m strong, I’m healthy, I can take care of patients and don’t need to take care of myself.” The idea that self-care is selfish persists, even among millennials, she has found, though it is more prevalent in older generations. “It’s a huge cultural shift to say that unless you take care of yourself, you really can’t take care of your patients,” Lawrence says.
Thus, initiatives aimed at residents and faculty make up an important adjunct to the four-year student wellness curriculum developed by her office. There is a wellness newsletter just for residents, and a recently completed baseline survey of wellness data from all School of Medicine residents.
For faculty, Lawrence is applying a three-pillar approach developed at Stanford, which aims to build personal resiliency, efficiency of practice and a culture of wellness. A new task force appointed by Chancellor Paul Roth and the Physician Advisory Group is looking into methods for improving workplace efficiency, while initiatives exploring a possible faculty lounge, more wellness classes and flexible work hours address the other two objectives.
Ultimately, the pursuit of provider wellness means acknowledging that doctors are human – and that human activities that bring joy and meaning play a contributing role, from the consulting room to the operating room.