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Accentuate the Positive: Appreciative Inquiry as a Tool for Combating Burnout

Article In Brief

One academic medical center has put into place a wellness program, based on the concept of appreciative inquiry, which asks neurology residents to explore their existing strengths and successes.

Christopher Traner, MD, a chief neurology resident at Yale School of Medicine, had become familiar with common approaches to combating physician and resident burnout—programs aimed at building resiliency in individual clinicians, such as mindfulness coaching, and efforts to identify and combat the stress factors, like a massive firehose-worthy flow of medical data to manage, that lead to burnout.

But when his assistant program director, Jeffrey Dewey, MD, assistant professor of neurology, invited him to be a part of a group of eight residents to do hour-long face-to-face interviews on a strategy for burnout prevention called “Appreciative Inquiry,” Dr. Traner was intrigued. “It sounded very different from anything I'd participated in before,” he said.

Searching for the Best in People

Appreciative Inquiry (AI) is a strengths-based, positive approach to leadership development and organizational change. Instead of approaches like a SWOT (strengths, weaknesses, opportunities and threats) analysis, which spend significant time on pitfalls and problems, AI asks people to explore strengths and successes that already exist.

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“As I began talking about patients I had cared for and positive interactions with them and their families, I realized how easy it is for those things to get lost in the day to day minutiae of being at work, writing notes, and helping discharge patients. Its easy to lose focus on why you went into medicine in the first place.”—DR. CHRISTOPHER TRANER

“At its heart, AI is about the search for the best in people, their organizations, and the strengths-filled, opportunity-rich world around them,” wrote David Cooperrider, PhD, a Distinguished University Professor at Case Western University and the originator of the concept, in a 2015 book on the appreciative inquiry process.

“AI is not so much a shift in the methods and models of organizational change, but AI is a fundamental shift in the overall perspective taken throughout the entire change process to ‘see’ the wholeness of the human system and to ‘inquire’ into that system's strengths, possibilities, and successes.”

Dr. Dewey can't remember where he first came across the concept of AI, but it immediately struck a chord with him. “I've always been very interested in positive psychology and optimal human performance, so it really resonated with my world view,” he said. He had also learned of a few academic medical centers that had applied AI across their institutions, including Indiana University School of Medicine and the University of Virginia Health System, which now has a Center on Appreciative Practice that has published a book on appreciative inquiry in health care.

So when he was selected to participate in the AAN's Live Well, Lead Well program, in which clinicians develop project-based initiatives for improving practice culture and reducing burnout, he decided it was the perfect opportunity to put AI into practice in the Yale neurology residency program.

The Five Ds

The full AI process is a cycle of “five Ds,” including Definition, Discovery, Dream, Design, and Destiny/Delivery; Dr. Dewey focused his project on the “discovery” phase, which involves interviewing stakeholders in an organization about what is working well and gives life to the institution.

“In the era of burnout, we know really well what isn't working,” he said. “It's easy to become focused on that and forget about the best of what we do. I wanted to understand what we were doing well and what helped the residents thrive, and to teach them this mode of thinking—how to focus on what's going well around them.”

In the pilot series of one-on-one interviews, Dr. Dewey spoke with Dr. Traner and seven other residents about how they found pleasure in their work and the things that motivated them to keep coming back. When in their residency did they feel at their absolute best? What circumstances led to those feelings?

“One thing he asked me was, ‘Tell me about a patient you recently cared for where you had a positive experience,’” Dr. Traner recalled. “As I began talking about patients I had cared for and positive interactions with them and their families, I realized how easy it is for those things to get lost in the day to day minutiae of being at work, writing notes, and helping discharge patients. It's easy to lose focus on why you went into medicine in the first place.”

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“What I like about AI is that it provides us with the opportunity to take a strength-based approach for growth within a group or department. Particularly in this time of tremendous change and uncertainty, its important to use positive psychology techniques to figure out where our strengths are as we try to navigate this rapidly evolving new landscape.”—DR. JENNIFER ROSE V. MOLANO

For example, Dr. Traner, who will stay at Yale for an epilepsy fellowship after completing his residency, told Dr. Dewey about a patient who works maintaining and supplying swimming pools.

“He was having trouble accessing care for his epilepsy because his work is so seasonal, and hospital admissions for epilepsy monitoring units are typically most open in the summer,” Dr. Traner said. “So I spent a lot of time working with him and eventually spoke to his boss and got a dispensation for him to take off work for an EMU admission. We were able to characterize his seizures and with medication adjustments, he's now been seizure-free for two years and it's really made all the difference in his life. This is one of the reasons I chose epilepsy as a subspecialty: people don't realize the toll a disease like that can take on someone, particularly with the social stigma. His positive experience is one that I always think about.”

Working Beyond the Comfort Zone

One surprising common theme that arose during these hour-long interviews, which were conducted under the auspices of an IRB-compliant study, was that of residents reporting some of their most positive experiences when pushed beyond their comfort zone.

“To a person, they all reported feeling positive about going through a clinical experience that stressed them—like the first time they covered call overnight—and being able to overcome that challenge,” said Dr. Dewey.

“For example, one resident described being early in their residency and doing a very intense emergency department shift where there were multiple stroke alerts and they felt like they were out of their element. But then later it hit them: ‘I'm doing this. I'm a neurologist now.’ This goes with the positive psychology concept of eustress, stress that leads to growth. Most people were not necessarily enjoying themselves in the moment, but as they reflected on those experiences, they saw them as some of the best moments of their residency.”

Almost all of these experiences involved situations in which the residents were required to act independently, with little or no supervision. “This suggests that we should focus on setting our residents up for experiences in which they are highly challenged, and yet have the opportunity to grow,” Dr. Dewey said. “And then we need to give them the opportunity to reflect on those experiences in a structured way, because the reflection is just as important as the experience itself to the appreciative inquiry process. That could be done in the moment, immediately afterward, or at a later time. But it should not be just once a year or once in a residency. We are great at setting up regular opportunities for our residents to debrief critical incidents or bad outcomes with things like morbidity and mortality conferences, but not so great at doing the same with moments of success and growth.”

The Ideal Practice Environment

After the eight one-on-one pilot interviews, Dr. Dewey assembled a larger focus group of all the neurology residents and paired them up to discuss what their ideal practice environment would look like, if there were no barriers.

“We brainstormed all kinds of ideas, like protected time for case conferences where some other entity could take care of the patients so we could focus on our discussion and our learning,” said Dr. Traner. “No ideas were off limits. Then we talked about how to take baby steps toward some of those goals and making them achievable. Having a positive attitude about work and making people feel appreciated at work is so important. You don't want to distract people from what the problems are, but rather, address them in a positive way.”

Jennifer Rose V. Molano, MD, FAAN, associate professor of neurology at the University of Cincinnati, FAAN, co-chair of the AAN's Wellness Joint Coordinating Council, and chair of the Live Well, Lead Well program said that Dr. Dewey's project was a natural fit, and could easily be replicated at other institutions—indeed, her department has already done so.

“Our chair, Dr. Brett Kissela, really believes in the idea that we need to take care of ourselves so that we can take care of our patients,” she said. “At our last half-day retreat for about 200 members of our department—faculty, learners and administrative, clinical and research staff—we included two appreciative inquiry exercises focused on joy in work and high-functioning teams.

“We had groups of ten per table, and each table had individual reflections followed by a table discussion, which they wrote up on a feedback sheet that was returned to leadership,” Dr. Molano said.

“What I like about AI is that it provides us with the opportunity to take a strength-based approach for growth within a group or department. Particularly in this time of tremendous change and uncertainty, it's important to use positive psychology techniques to figure out where our strengths are as we try to navigate this rapidly evolving new landscape.”