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Focus Groups Helps Identify Key Systemic Issues for Battling Burnout

Article In Brief

Clinicians used focus groups at an institution to identify sources of burnout before beginning to address them via systemic changes.

When Deborah Young Bradshaw, MD, FAAN, decided to tackle burnout in her department, she took guidance from the Mayo Clinic, a leader in clinician wellbeing research and mitigation strategies for the past decade.

In 2017, Tait Shanafelt, MD, director of Mayo's Program on Physician Well-being until he moved to Stanford University, and John H. Noseworthy, MD, FAAN, Mayo's president and chief executive officer, published an article, “Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout,” about the Clinic's anti-burnout strategies. Dr. Bradshaw liked what she read.

“I am following the recipe because it's a proven recipe, and it tells me what to do step-by-step,” said Dr. Bradshaw, associate chair for education and residency program director in the neurology department at State University of New York Upstate Medical University in Syracuse.

As a member of the AAN's Lead Well, Live Well 2018 cohort, Dr. Bradshaw is leading her department through the first three strategies in the Mayo paper: 1) acknowledge and assess the problem; 2) harness the power of leadership; and 3) develop and implement targeted interventions.

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“The behaviors of physician leaders are very important to physician well-being—this is a huge thing to me that came out of Mayos work. They found just a slight increase in leadership skill of those in leader positions led to a several point reduction in burnout.”—DR. DEBORAH YOUNG BRADSHAW

“We're taking a tactical approach to burnout,” said Luis J. Mejico, MD, FAAN, chair of the neurology department.

Results from a department survey found that 73 percent of full-time faculty members reported at least one burnout symptom, compared with 60 percent of neurologists nationally (a finding of the AAN's survey conducted in 2016). On the other hand, 63 percent of Upstate residents reported at least one burnout symptom, compared with 73 percent of neurology residents nationally (a finding of another AAN survey conducted in 2016.)

Despite the high burnout rate, faculty members reported high levels of meaning in their work. “So people are exhausted, but they still find their work meaningful, which I think is what keeps them going,” Dr. Bradshaw said.

Another takeaway from the survey findings: Fourth year residents reported a lower number of work hours and better sleep than their colleagues in earlier years, but higher levels of interpersonal disengagement. “And you can see it when you talk to them,” Dr. Bradshaw said. “Cynicism, which is the core of burnout, accumulates, regardless of work hours.”

The survey was followed by focus groups—two for those working in the outpatient clinic; one for neurologists working in stroke/ICU; one for residents—to collect their ideas about burnout drivers and potential solutions. Other subgroups such as neurologists who work on the stroke service will have focus groups in the future.

“This step, simple as it may be, has allowed our faculty members to realize that they are not alone and that they are being heard,” Dr. Mejico said. “This has given them hope that there is going to be improvement.”

The sessions identified some straightforward issues—for example, how after-hours outpatient telephone calls are handled—that are being immediately addressed by clinic or division-level leaders. Task groups will be created to address more complex issues, Dr. Mejico said.

Meanwhile, Dr. Bradshaw was inspired by Mayo's No. 2 strategy—harness the power of leadership—to develop a leadership curriculum for neurology residents.

“The behaviors of physician leaders are very important to physician well-being—this is a huge thing to me that came out of Mayo's work,” she said. “They found just a slight increase in leadership skill of those in leader positions led to a several point reduction in burnout.”

The three-year Leadership Academy curriculum, which launched this year, consists of monthly noon conferences to teach residents the core qualities of leadership. First-year residents will be introduced to basic concepts such as effective listening and building successful teams. Second-year residents will practice skills such as difficult conversations and conflict resolution, and third-year residents will teach the curriculum to their younger colleagues.

“We're taking a tactical approach to burnout.”

—DR. LUIS J. MEJICO

Faculty members will develop and present modules on topics of their choice, such as emotional intelligence or leadership styles. “Our faculty seems really interested and excited about it,” Dr. Bradshaw said. “This is stuff they want to know for themselves.”

Former AAN President Terrence L. Cascino, MD, FAAN, a professor of neurology at Mayo and chair of the AAN's Leadership Development Committee, was recruited to come to Syracuse this summer to kick off the Leadership Academy.

Tips From the Front Lines

Dr. Bradshaw shared these details for others who might want to follow her lead.

Because she wanted to benchmark her department's results against those of neurologists nationwide, Dr. Bradshaw chose the survey instrument developed by AAN for its nationwide study of neurologists in 2016. She modified the instrument by replacing the Maslach Burnout Inventory, which requires payment for its use, with the Stanford Professional Fulfillment Index, which can be used at no charge. She also added some questions about sleep, which is associated with clinician well-being.

The survey was fielded for one week; 100 percent of residents and 85 percent of faculty members participated.

Each focus group was led by a faculty member who does not work directly with the focus group participants. A movement disorder specialist led the group for neurologists on the stroke team, for example.

“I recruited individuals who would be a neutral person,” Dr. Bradshaw said. “I asked the section leaders not to attend (the focus groups for their work units) so that faculty could be forthcoming and not worry about hurting feelings.”

She gave each leader a PowerPoint presentation to guide the discussion and coached them to focus on issues within the purview of the department rather than those—for example, electronic health record technology and quality metrics for performance monitoring.

“The Mayo people said, ‘Try not to spend a long time on stuff we can't fix,’” Dr. Bradshaw said. “So let's try to focus on things that are within our ability to change.”

The leader used participants' feedbacks to create a list of the main burnout drivers identified by the group.

Rohit Swarnkar, MD, who finished his residency at Upstate this spring, said the focus group was worthwhile because it gave participants an opportunity to share their perspective.

“The questions were pretty open-ended—‘What do you think is an undue burden on your time?’ and ‘Is there something we could take off your plate that would improve your educational experience?’” he said.

Beyond Neurology at Upstate

As Dr. Bradshaw pointed out, many significant burnout drivers, such as electronic medical record (EMR) technology, cannot be addressed at the department level. Amy Tucker, MD, Upstate's chief medical officer, Leslie J. Kohman, MD, president of the medical staff, and members of the Upstate Well-Being Task Force are tackling those.

“The EMR that we have has been a pain point for our clinicians, as for clinicians nationwide,” Dr. Tucker said.

A brief survey of the medical staff was conducted to ask two main questions: 1) What changes in the EMR system would make your life better? 2) What changes in the medical staff environment would make your life better?

In response to the many suggestions for improving the EMR system, an EMR usability group has been created and voice recognition software is being added to reduce the number of clicks and amount of scrolling that physicians must do each day.

“The second thing people wanted was a space where medical staff members have somewhere to sit down, hang their coats, get a cup of coffee, and interact with each other,” Dr. Kohman, a thoracic surgeon, said. To that end, Upstate leaders have agreed to create a Clinical Collaboration Center, something akin to the doctors' lounges that used to be commonplace in hospitals.

Physicians also expressed dissatisfaction with some professional aspects of their work. “The medical staff feels like they're not getting proper recognition and respect for all the very hard, difficult, and excessive work that they feel that they're doing,” Dr. Kohman said.

That will be addressed by increasing opportunities for committee appointments and leadership opportunities for younger faculty members and finding ways to improve the working relationships.

“We know that a person's well-being at work is largely based on their interaction with their immediate supervisor, and we really want to enhance those relationships,” Dr. Kohman said.

While wellness initiatives that support personal resilience are important, Dr. Kohman made a point to say that is not the top priority.

“The most important thing is to fix the systemic barriers so that people can be their best at work and feel their best,” she said.

Link Up for More Information

• Shanafelt T, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout https://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/pdf. Mayo Clinic Proc 2017;92(1):129–146.
    • Busis NA, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurologists in 2016 https://n.neurology.org/content/88/8/797.long. Neurology 2017;88(8):797–808.
      • Trockel M, Bohman B, Lesure E, et al. A brief instrument to assess both burnout and professional fulfillment in physicians: Reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians https://link.springer.com/article/10.1007%2Fs40596-017-0849-3. Acad Psychiatry 2018;42(1):11–24.
        • Levin KH, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016 https://n.neurology.org/content/89/5/492.long. Neurology 2017;89(5):492–501.