What's stressing physicians out? A loaded question for sure, but one that begs an answer in light of an Aug. 20 paper published online in the Archives of Internal Medicine that reported that the burnout rate among physicians — and neurologists in particular — appears significantly higher than that of the general population.
Among 7,300 physicians surveyed, 46 percent showed at least one symptom of burnout (using the Maslach Burnout Inventory). Neurologists had the third highest rates of symptoms (OR, 1.47; p=.01) — with more than 50 percent showing a sign of burnout. Moreover, compared with the sample of about 3,400 working US adults, physicians were more likely to have symptoms of burnout (37.9 vs. 27.8 percent) and to be dissatisfied with work-life balance (40.2 vs. 23.2 percent), (p<.001 for both).
Henry J. Kaminski, MD, chair of the department of neurology at George Washington University — who moderated a special faculty development session developed by the Association of University of Professors of Neurology (AUPN) here at last month's annual meeting of the American Neurological Association (ANA) — told Neurology Today that at the last business meeting of the AUPN, “we had a group of 40 chairs or program directors discussing their job challenges….And it was pretty clear in that room that there are a lot of frustrations and increasing concern that leaders in the field are feeling more stress and discontent with their positions.”
There are many causes for their burnout, said Dr. Kaminski, who is also councilor for the ANA, and president of the AUPN. Leaders may feel increasingly distressed because of increased financial and budgetary pressures to drive clinical and research revenue with less funding support, he said, balanced with the need to recruit and retain the best faculty while developing their own careers.
[Neurologists in private practice as well may feel besieged by financial pressures and increasing demands to keep up with regulatory requirements and the looming salary declines due to loss of consultation codes, Neurology Today associate editor Orly Avitzur, MD, wrote in a series of several articles in 2010 and 2012: http://bit.ly/drFzbu; http://bit.ly/QPQudV.]
On the faculty side, the AUPN is in the process of creating a mentorship network for new chairs, he said, providing a colleague in a more senior chair position or a former chair that will reach out and discuss any issues that may arise. Often times, there's nobody in the department or in one's medical school with whom you can discuss a difficult or challenging situation and this program allows you to ask advice with the guarantee of anonymity (at least to your institution), he said.
“The leadership at the University of Virginia [UVA] already had appreciated this problem and started a program for faculty there to prevent burnout through programs that provide psychological and career development support for their faculty at all levels, and they are extending it to the leadership in neurology,” he told Neurology Today. The program, which was featured here at the ANA meeting, is focused on academic faculty, but the underlying philosophy and approach to addressing burnout may apply to neurologists who work in a broad range of other non-academic settings.
THE ROOT CAUSES OF BURNOUT
Sharon L. Hostler, MD, McLemore Birdsong professor of pediatrics; vice provost for faculty development; and senior associate dean at UVA School of Medicine in Charlottesville, heads the program with Steven T. DeKosky, MD, a neurologist who is vice president and dean of the UVA School of Medicine.
In interviews with Neurology Today, she and John Schorling, MD, MPH, professor of medicine and director of the UVA Mindfulness Center and the Physician Wellness Program, discussed the causes of burnout, and the program's philosophy and approach to dealing with it.
The UVA Faculty Leadership program, which aims to help faculty understand and manage the stressors causing their burnout, is centered on the notion of emotional intelligence described by psychologist and author Daniel Goleman, PhD. [In a series of books and articles, Dr. Goleman asserts that non-cognitive social skills are as important as IQ for workplace success and effective leading.] The program provides faculty with tools that promote enhanced self-awareness and management, she said, as well as awareness of their colleagues' needs so they can manage those relationships more effectively.
The goal is to keep faculty engaged and address recognized symptoms of burnout — emotional exhaustion, depersonalization, and a reduced sense of accomplishment. The program offers wellness initiatives — for example, free yoga classes and mindfulness sessions — and seminars that address the challenges head-on.
Depersonalization — “when we start to talk about the patients or students and depersonalize them, or we actually objectify them and put them in a ‘box,’” — is probably the most sensitive measure of burnout, Dr. Hostler said. “We've discovered that once faculty get over that line, it's very hard to pull them back in,” she said.
Especially in academic medicine, we have a tremendous sense of personal accomplishment so we are able to tolerate some of the emotional exhaustion and the time exhaustion because we get that feedback from our patients, she said. “Once that feeling of positive feedback goes away, it is very difficult to get it back.”
The two most important causes of burnout in the workplace, Dr. Schorling said, “are increased workload and decreased control — and that has pretty much defined the health care environment that we are in now.”
Plus, physicians tend to be perfectionists, Dr. Schorling continued. These “traits make us good doctors and make us pay attention to detail and follow up with our patients so that we don't overlook important factors. But that same perfectionism can lead to exceptionally high standards and self-criticism when things don't go as intended,” he added. “When you combine that with the current environment of decreasing control, it often leads to a situation where physicians feel increasingly frustrated,” Dr. Schorling said.
QUESTIONS WORTH ASKING
It can be easy to get overwhelmed when things aren't going as planned, he said. But it is important to slow down and focus on these questions: Why did you get into the field in the first place? What do you feel rewards from? What brings you joy? Just thinking about those things and writing them down is important, he added.
“There's an exercise that comes from [the management consultant and author] Stephen Covey that's called ‘Beginning with the End in Mind’ [stephencovey.com/7habits/7habits-habit2.php] — the idea is to say, when I'm done with all of this, what do I want my career to have meant? What are the most important things in my life? Am I on that path — and, if not, how can I make the right connections?”
For most of us well-being and job satisfaction come from the choices we make — often difficult ones, he said. “Saying no is not easy, but often to achieve the things that are really most important for individuals, we need to learn to and be able to say no.”
Another useful exercise, according to Dr. Holster, focuses on the week as a unit of 168 hours. “If you write down your core values and what you really want to accomplish, and then chart out how you have spent your last 168 hours, you can ask: what do you need to give up, what do you need to do more of, and are you essentially ‘walking the talk’?”
This, she said, is how you begin to sort through your choices and priorities.
We're beginning to notice, when we examine burnout, that the stresses are different generationally, Dr. Hostler added. “For our senior faculty at UVA, EHRs [electronic health records] are a major source of stress,” she said, while more junior faculty may struggle with managing careers with home life.
“In many ways the senior boomers and traditionalists created the current structures like promotion and tenure timelines during a period that reflected the lives of married white men of a certain privilege who had someone at home taking care of things and someone in the office or the lab taking care of things.
“Now, expectations are evolving to reflect a new, different generation,” Dr. Hostler said. The junior faculty members come in and expect that they will have time with family, that they'll have personal time — and they often have a faster track of being able to demonstrate their capacity for productivity, promotion and tenure, she said; so the tensions between generations are often about values, workloads, and performance.
The other generational distinction is the way we give and expect feedback, Dr. Hostler said. “The younger faculty and residents expect moment-to-moment feedback and the traditionalists and senior boomers expect that they'll only hear about something if it goes wrong.” In response, Dr. Hostler points to the importance of rewarding faculty for their work — and doing so in front of others — including family members. In order to encourage a high sense of personal accomplishment among all staff and retain new employees, it is vital for chairs and senior staff to keep these intergenerational differences in mind.
To bridge generational gaps and enliven the conversation between faculty, Dr. Hostler said, the program regularly involves faculty in role-playing sessions. A role-playing scenario may include, for example, a research mentor and a young millennial who wants be in the Peace Corps, but also wants to complete her PhD in neuroscience.
Another scenario may involve a department chair — a very senior, well-funded male — who has not been paying attention to the different needs of junior faculty and the fact that young mothers in dual-career partnerships may have a different set of tensions and they may be recruited away to another institution.
“We approach these situations in many different ways — it might look like a salary negotiation or it can look like a retention, but the underlying conversation is about the young person feeling valued differently,” Dr. Hostler said.
‘COMMUNITIES OF TRUST’
Aside from the straightforward presentations we do, Dr. Schorling said, we try to create what we call “communities of trust,” and often our participants end up talking about very personal issues. The UVA School of Medicine monthly lunch program allows for discussion about parenting, dual-career families, family illness, retirement, and related topics.
“Sometimes they are surprised that they have chosen to share such things, but there is a very positive outcome — even if it's just knowing they are not alone, or sometimes they receive practical advice,” he said.
For example, some discussions have included questions about time-management and housekeeping: Is it really is okay to pay somebody to cook your meals or make your Halloween costumes? Is it okay to pay someone to clean your house — especially when they never do it as well as you think it should be done?
“Our last Transition and Change session topic was ‘Be Careful What You Wish For: Taking on New Responsibilities.’ We had five or six storytellers and about 35 attendees,” Dr. Hostler said. One storyteller was a brand new faculty member, learning to balance the wealth of choices with caring for a four-month-old. Another was a very senior individual who discussed his history of saying no — to the chair, to the dean — and how it took five years to find the ideal interdisciplinary work he wanted, “but he did find it and only by saying no to what looked like really great opportunities,” she said.
Ideally, at the end of one of their sessions, a young neurologist may be walking out in conversation with a senior cell biologist (as was the outcome of a recent program) — “it's that person-to-person connection that may be the most powerful outcome of anything that we do,” Dr. Hostler explained.
What we've learned from our follow up, she said, is that these interpersonal connections are what lead to real changes in how we learn new skills or let go of old behavior — and they enable people to find more satisfaction and more personal accomplishment, which, again, is the opposite of burnout.
“Seeking meaning and staying connected to the work that we do has been called the principal antidote to burnout,” Dr. Schorling said. “Individuals who can stay positively connected — focusing on what they are doing well — are less likely to experience burnout.”
The column is part of Neurology Today's series on innovative models for service delivery and professional development. Earlier this year, the series featured a unique program for Alzheimer's disease patients: http://bit.ly/N087Tr. Have a program you'd like to share with us? E-mail NeuroToday@LWWNY.com.
LISTEN UP: TUNE IN: To learn more about burnout among neurology chairs and senior faculty, tune in to the interview with Henry J. Kaminski, MD, chair of the department of neurology at the George Washington University: http://bit.ly/rCBryX.
STRATEGIES TO ADDRESS BURNOUT
The University of Virginia (UVA) offers specific programs to promote good health, self-awareness, and reflection. Participating in these types of programs or approaches may be useful for clinicians in all settings. For example:
* The mindfulness center at UVA (uvamindfulnesscenter.org) includes classes based in mindfulness meditation that are specifically geared towards health care faculty, with a goal of improved patient communication, reduced work stress, and better work/personal life balance.
* The UVA School of Nursing offers free yoga and meditation classes open to anyone in the health system.
* The UVA program encourages expressive writing, or taking time to write about an event, as well as the emotions and thought process involved. Hospital Drive, an online literary journal published by the UVA School of Medicine (hospitaldrive.med.virginia.edu), provides an outlet for faculty and staff to publish those musings. The Taos Writing Retreat for Health Professionals is a week-long opportunity for reflection on professional and personal matters in a historic locale in New Mexico (taoswritingretreat.com).
* To prepare new chairs for leadership, the UVA offers monthly “Chair On-Boarding” sessions that consist of case-based presentations on retentions, budgets, and evaluations.
* A new orientation program provides an opportunity for new faculty to meet with seasoned clinicians and researchers. Valuable resources for health faculty are also outlined (http://bit.ly/TdTrqQ).
For a full listing of programs and course offerings, visit: http://bit.ly/UTFoUO.
FOR FURTHER READING:
• Shanafelt TD, Boone S, Oreskovich MR, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; E-pub 2012 Aug. 20.©2012 American Academy of Neurology
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