I was privileged to address this important topic in my keynote speech to the Spring Minnesota Medical Group Management Association (MMGMA) conference in March 2016, in which I addressed Executive Directors, HR Directors, Administrators, and other healthcare professionals on the hanging state of healthcare, the impact it is having on physicians (and other healthcare professionals), and the subsequent rise in burn out among physicians. Unfortunately, I saw many heads nodding in agreement with what I shared, and heard from many after my talk what a growing problem this is becoming for their organization. I fear the problem will continue to worsen unless we act NOW to help those who are dedicated to healing others.
From a healthcare perspective, the last several years have seen accelerated change in the healthcare landscape. For example:
• Rising costs mean that the smaller, independent physician groups are being bought or merged with larger healthcare organizations to stay alive and/or relevant
• Decreased reimbursement, particularly from Medicare, is creating a “vicious circle”of needing to work harder and longer for the same (or less) pay – even after a “buy out” or merger with a larger entity
• The enactment of digitized medical records have, however inadvertently, made the doctor-patient interaction less patient centered and less personal, increasing the stress and frustration on both sides
• ICD-10 coding, which may be much more specific, AND a lot more costly and time consuming
• All of this (and more) results in the increased pressure to do what has become a mantra in many hospitals and clinics I consult to: “Do more with less”
These things are hardly new and, in fact, are fast becoming the “new normal.” So, what’s the impact of these changes on the physicians I coach?
I consult to a medical group in another state – currently the largest independent group of their specialty in the U.S. – who are busier than ever and are dedicated to providing excellence in healthcare. In their specialty, like the rest of healthcare, if mistakes are made, people can die. It is that simple and that true.
I was interviewing many of their Shareholders to help understand the dynamics they were facing in their daily practice. Complaints were at an all time high, “back biting” was prevalent, revenue (and thus income) were down for the second consecutive year despite being busier than ever, Shareholders distrusted Administration, and complaints of burn out were openly discussed. When asked what was having the biggest impact on their practice, one f the Shareholders summed up his experience in one sentence,
“I’m moving at the speed of malpractice.”
That simple, and yet it spoke volumes. So, what does moving at the speed of malpractice look like?
• Increased pressure to see more patients, necessitating that physicians spend less time with each in order to see them all in a schedule keeping manner.
• With increased pressure to move quickly, physicians become stressed and affect (tone of voice) often becomes more stressed and tight. Patients pick up on this and it stresses the clinic visit. This negatively impacts the doctor-patient relationship, often culminating in more patient complaints about physicians. With staff, this dynamic can lead to things being taken more personally.
• When (not if) this happens, more mistakes are made because people are preoccupied with perceptions of being treated disrespectfully. The time needed to be as thorough as needed isn’t always taken. Communications between physicians
and staff are transmitted quickly because of the underlying pressure to keep moving quickly, often resulting in more misunderstandings or miscommunications
(By the way, this happens with patients as well!) Staff complain about the physician and the physician complains about the staff. And ‘round and ‘round it goes…Why does this matter?
The Mayo Clinic Study (Mayo Foundation for Medical Education and Research; Mayo Clin Proc. December 2015; 90(12):1600-1613) (http://dx.doi.org/10.1016/j.mayocp.2015.08.023) examined physician burnout and work life balance (WLB) comparing the years 2011 and 2014. They found that over half of U.S. physicians experience at least one of the following indicators of professional burnout:
• Emotional Exhaustion
• Loss of meaning in work
• Feelings of ineffectiveness
• Depersonalization (tendency to view people as objects vs. human beings)
• Patient safety becomes compromised
From that, Mayo observed that the quality of care that physicians provide decreases and that physician turnover increases – all of which combines to significantly impact (negatively) the quality of the healthcare delivery system.
Physician burnout increased from 45.5% in 2011 to 54.4% in 2014. While some specialties suffered more than others, ALL specialties saw at least a 10% increase. Compared to the general population, physicians were at 48.8% vs. 28.4% and for work life balance satisfaction, physicians were at 36% vs. 61.3% for the general population. As you can see, physicians (and healthcare staff, for that matter) are under the a great amount of stress and pressure and they are feeling it!
Hospital errors are now the third (3rd) leading cause of death, behind heart disease and cancer, estimated between 220,000 – 450,000 deaths per year (Journal of Patient Safety, Sept. 2013, Volume 9, Issue 3, pp. 122-128). While there are many factors contributing to this, the research specifically identifies the following as contributing factors: Increased production demands; Decreased staff; and shortage of physicians, which then lead to fatigue and burnout. Not surprisingly, this mirrors much of the Mayo Clinic’s findings.
I have been coaching physicians for over 25 years and have noticed several recurrent themes that bring them to my door. Here are a few of the most common:
1. The physician cares. In fact, sometimes too much. They went into medicine to help people, to make a difference and practice the art and science of medicine. When they experience a “system” that isn’t working well, or efficiently, or effectively, or D) all of the above, they often get stressed and frustrated because their work is hampered by forces typically outside their control. Their heart (intentions) comes from a good and positive place – and they find the “landscape” of healthcare today rubbing them the wrong way from how they knew to practice. Truth be told, this is more true for the “old school” physician vs. new(er) graduates who have not known how medicine was 20 years ago. Regardless, they often “rail against the system” in order to meet their patient needs as best and as quickly as possible.
2. Because there is little to no margin for error in healthcare without deleterious consequences, they are held to the highest standards, by the healthcare system, patients and their families, and by their own selves. When that isn’t attainable on a regular basis, stress and frustration rise, and often comes out on those around them (usually staff/partners, but patients, too).
3. The pressure to do more with less (but have the same excellent outcomes) takes a toll on their self esteem, their sense of effectiveness and making a difference, and they become increasingly disengaged – they begin to care “less” so the daily frustrations don’t bother them as much.
4. The increased production that is expected (to meet patient demand AND demands of the practice to “earn their keep”) takes a toll on the physician and his or her family. They are absent from the home more, missing out on raising their kids, and when they are home, typically exhausted or finishing dictation.
5. Physicians often have poor stress management skills because it isn’t something taught or emphasized in med school. Again, the larger recurrent theme is one of increased risk for burnout because of many simultaneous factors. While many may be out of immediate control, many are not and
can be more effectively managed.
There are many things that can be done to curtail and minimize physician burnout. It is important to note, as the Mayo Clinic did in their study, that the most effective process includes interventions that happen at a systemic AND individual level.
1. Identify systemic concerns/issues sooner. How might they know if something is an issue? Follow the complaints. It is far easier to discount a “naysayer,” someone who is complaining about something, than look into the merits of the complaint. Time after time, I have discovered that the physician I am coaching had merit in their complaint, but were made to engage in executive coaching because of HOW they went about making their voice heard. Relatedly, if a physician is being identified as having issues or concerns (because of complaints being made by colleagues/staff), act sooner rather than later and address the concerns before they become even more disruptive.
2. Develop an accountability process/procedure. Every organization should have a stepped or gradated process for addressing behavior issues in the workplace that apply to everyone at all levels within the organization. This helps with the “fairness” or ”equitable” concern and helps decrease the possibility for others to raise the discrimination flag if they believe how they were treated was different from another. This also spells out the process that will be followed when there have been infractions and lends a sense of “safety” to the culture of the organization.
3. Physician Self-Monitoring and Board of Director Development. It is unreasonable to think that staff will hold physicians (oftentimes their boss) accountable for inappropriate or unprofessional behavior, despite whatever the rules are or the permission given to them to hold others accountable. I have found that physicians need to hold their peers accountable, and if they don’t, then Leadership must (whether it takes the form of a Board of Directors, Administration, HR, etc…). When Leadership does not hold physicians accountable to behavioral standards and expectations, morale drops and employees feel less safe that their concerns will be heard and respected. They go “underground” or silent, causing the old adage, “What
you don’t know may hurt you”.
4. Training. At times, it is important to train employees – physicians and staff alike – in certain key workplace behaviors, such as Conflict Management, Professional Boundaries in the Workplace, Dealing with Difficult Situations/People, and the like. This often goes hand in hand to create…
5. Developing a Positive Organizational Culture. By engaging in the above, organizations can more positively shape the culture of the organization in such a way to minimize disruptive behaviors and attitudes and emphasize the care and commitment to the people who comprise the organization. When staff feel happy and healthy – cared about – it is transmitted to those who engage the organization, namely, patients and their families.
Physicians come to me for a wide variety of issues and concerns, but more often than not, it is because they are experiencing what has been described above and they have maxed out their coping mechanisms. At the risk of oversimplification, I help physicians with the following:
1. I listen to their concerns. I’ve already been apprised from Administration what they see as the problem or issues, now I want to hear things from the physician’s perspective. There is overlap, no doubt, but I also hear things from the angle of the person in the “trenches” who is trying to navigate meeting multiple needs (of the healthcare system, the parent organization, the clinic, the patient, etc…) in a fast moving system where they tend to run perennially behind – and are doing the level best they can. I slow things down so we can examine them more closely and determine what is within their control and what is not.
2. I help them mange their emotions so their emotions do not manage them. This happens in many ways, including Stress Management; “Self” Management (managing their selves, not outcomes, which may have many variables outside their control influencing things); Impulse Control (because you think or feel it doesn’t mean you should say it); and helping them “slow down” inside so they give themselves time to think before they speak.
3. Be in the Present (mentally), not the past or future. In short, the only time we have control over anything is in the present. Staying mentally in the present helps them to be more thoughtful about what would be helpful NOW and it is highly effective in minimizing stress, pressure, and anxiety (all things associated with too much mental time in the future).
4. Development of EQ (Emotional Intelligence) in a high IQ environment.
Physicians are, on the whole, a very bright bunch of people. That said, their intelligence may be more “narrowly” focused, often excluding the skill sets identified as necessary for working well with others. This has been called Emotional Intelligence (EI or EQ for short). Study after study has found that EQ is a more accurate predictor of success in life (not just work) than IQ. Learning to read situations, have empathy, be flexible, know how you feel and how it may impact others or the situation, etc…are all things EQ. I have every physician I coach take the BarOn EQ-i, an emotional intelligence assessment inventory, to determine where their skills are – and aren’t. Developing these “soft” skills, as they’ve been called, is the social lubricant that makes them more communicative, better team members, and overall more effective in leading a healthcare team.
5. Last, but certainly not least, I help physicians explore their underlying attitudes and beliefs that give rise to their behavior. Day in and day out, we CANNOT act against our underlying attitude and belief system. Belief systems (and we all have them) are like the operating system of a computer. We can’t see them, but they are quietly and constantly running behind the scenes, dictating what we can do or not. Once we bring them into awareness, we have the power to examine them, keeping what works for us, discarding what doesn’t, and adopting new ones that fit who we
are and our current situation. In the words of Mahatma Gandhi:
Your beliefs become your thoughts
Your thoughts become your words
Your words become your actions
Your actions becomes your habits
Your habits become your values
Your values become your destiny
As healthcare continues to evolve, the constant in all the change will be our caregivers. We need to ensure we are helping our healers (and healthcare organizations) to stay healthy, so they may continue to heal all of us.
Dr. Gregory Alch, Ed.D., is a Licensed Psychologist (M.A.) and Organization Consultant in practice for over 28 years. He is the Founder and President of Method 44, an organization consulting group. He works extensively with healthcare organizations providing executive coaching, leadership development, team building, training, and other change initiatives focused on bringing out the best in physicians and their employees in positive and productive ways. Dr. Alch’s offices are located in Edina, MN