Showing what burnout looks like and why it matters, internist Sunita Mutha, MD, discusses common symptoms, the many negative consequences for the health care field, and proven interventions. In a time when the problem is increasing and effective responses are crucial, she explains what steps organizations can take as well as how exhausted clinicians can help themselves right now.
this is a topic that I think we all hear a lot about. And I'm hoping that one of the things I will do is really trying to anchor it in what's the bigger picture, what's happening nationally, what are some of the trends look like and what are we learning? Because the science in this area is um, is news, but, and I want to Sprinkle that in with really just uh practical examples and then a couple of places like invite you to to enter into chat and we'll certainly have time for question and answer. So we'll do that. I want to start with the personal story because it's always anchors us in. Uh, and I think in the things that have happened and the things that we experience, I've been practicing this varnish, said for quite a long time, I'm a primary care physician to finish clinic this morning. And uh, and I really think of myself as a glass half full person that has been my orientation. I'm the the person that's always going to pitch in if there's uh, you know, somebody who needs to be out or someone who needs support that is my orientation. And so imagine my great surprise and sometimes disappointment when a few years ago I realized that I just wasn't feeling it. I just wanted to get through. I sighed a lot. Apparently I didn't realize that and I was in the room charting and my colleague would say, you know, you're sighing a lot. Um and I started to realize that there was something that was experiencing that were just maybe not show up in the way that I really wanted to show up and hope to show up. And I think that if I look back on that episode, I certainly didn't evaluate it in the way we think about it now, I would say I probably had some bit of burnout for sure. Um and wasn't showing up in the way I'd like to or as fully as I wanted to unfortunate uh that that period has gone past me and perhaps some of you have experienced that yourself and that's part of my motivation, really wanting to understand this and wanting to understand both actions that I could take things that felt meaningful and to understand the larger picture of what was happening in our environment. So think of, you know, think of my story and perhaps you have others, but we'll jump in and we'll talk a little bit about what this topic is. So as uh As you heard, I'm a primary care physician, I say that because that's really important to me and continue to practice and and find joy in doing that. I do direct health care center, we are almost 30 years old. We really focus on human capital. And the simple way I talk about it is like we're all about the people in health care, whether it's understanding who's in health care and what the distribution looks like in our state to corporation to scopes of practice to how do we make this all better. Um, and what's the best way to use the most valuable resource we have and you can see here sort of what we are focused on what we're anything to do. And we do that in a couple of different ways. Uh, focus on looking at research and action. And I say this because a lot of the things that I'm going to talk to you about really come out of some work we did last year looking um, nationally with the thunder on what is going on with wellbeing. That's the other side of burnout and we'll talk about that and we'll do that framing for you. Um, and we do consulting an evaluation work. We do a lot of work around leadership and leadership development. We run a statewide program for clinician leaders who come from all different parts of our health care system. And uh, we spent two years with them and really train and transform them to be the most effective leaders, connect them to others up and down the state and outside the state, um, and help them really drive their organization's mission in the most effective way. So you'll hear about that and you can probably hear in my voice, these are things I'm really passionate about and I'm lucky to be able to do so to our conversation today. I want to talk about what burnout is, why it matters and why does well being matter what contributes and what improves well being. So what I want to do is I want to talk about burnout. There's been a lot of conversation about and I'll show you in a moment what kind of what the history has been is not new but our attention and perhaps the the prevalence of it has changed and it may in part have to do with the fact that we are able to measure it. So this is what burnout is in a slide. It is. We know that about 54% or so physicians, it's from national data have at least one symptom of burnout and these are some of the symptoms. Um some of the markers of it. A lot of this comes out of work that the Mayo clinic did going back about eight years or so just saying what's going on? How do we measure this? How do we look at it and then how can we improve? And in the recent years you've started to see an increase and you started to see a corresponding decrease in satisfaction. Now we'll tell you we are as a group physicians are incredibly resilient. We are when the measures have been done were among the most resilient um professions that there are and um what we're experiencing here and what's been coming out of this data is actually not unique to physicians. It's in health care. There's newer data coming out about nursing and shows that perhaps burnout in nurses and this is whether it's inpatient outpatient, all of that is perhaps even higher. Then you can see in here some of the consequences of problems associated that studies have shown seem to occur. And we talk about this again, I'm just a little bit better. Right, And I'll show you a bit more data. So let me show you a little bit about this history of art because I have to tell you that when I think and hear about burnout, it's been something that's been increasingly part of the conversation that comes up or you see it in in the public and les publications. Um and in the peer reviewed publications. Um I was really thinking it was much more when I started this work, it's like, oh, this is really the last five years or maybe it's the last 10 years or sometimes we all like to blame it on the E H R. Right? Like that's that's the source of all of this. Well, it's not, it goes back much further and you can see in here and I won't read this every bit to you, but we can see that it started to first the concept of burnout and the definition of it really came out early, many decades ago. Then we have an inventory that's been adopted by Mazda two healthcare professionals And then we start to see studies come up and a really important point was in 2014 when the Institute for Health Care Improvement came up with um and sort of advanced actually tom Bodenheimer as a family physician retired from UCSF came up with this concept of the quadruple aim, take that triple aim that we talked about for so long. We want better outcomes for patients who wanted at a lower cost and we want to improve patient experience and add to it that we have to have an improved clinician experience that we're aiming for all of those things as our goal. And as you can see on the rest of the slide, one of the things that's happened is over time, people have really started to look at this is important enough that we have to think about it in our extreme of our work and how do we think about improving joy and work and not just looking at the negative, which is the burnout and burnout factors and characteristics, but what about well being? Because well being can exist. That's what we're really aiming and moving towards. What does it look like? How do we measure in? Um and I added in here, one of the things that has come up that I think is may be different in healthcare than it is in other fields is this idea of moral injury and this is really defined as um the context where you simultaneously know what the right things are to do or you believe you do the best things perhaps for patients individual or at the population level. But sometimes you're not able to because of constraints that are beyond your control. They might have to do with patients access to resources, they might have to do with insurance issues. They might have to do with other things that are that are beyond the control of the individual clinician. And yet it has an impact on individuals. And so that concept came up, you know, and I think at this point it is still more of a academic concept because what do you do with that? How do you address it? So really in um if you are a somebody who likes to read about this or understand the field, you'll see this description of moral injury for health professionals. You'll see more of it came up around the time of Covid when for a short while we did have issues with adequate access to PPE everywhere. And that was when people started to say it's just so difficult to ask people to do the work that they do and they joyfully do and to be in constrained circumstances. Now, fortunately for some of those things, we are beyond that. Um but it is a part of what happens in um in this arena of health care. And more recently, the W. H. O. The World Health Organization has designated thrown out in medical condition. This is not unique to clinicians. It's not unique as I said uh to physicians, but it's the recognition that internationally there is a trend towards and unawareness and what's, sorry, going too fast. So I want to talk a little bit about the so what, Okay, so you can say, yep, burnout exists. I get it. I see the slide. I see what, what some of those emotions might be in some of the experience. Excuse me, experiences well, so what the somewhat is actually pretty significant. This is really interesting and actually pretty good data, excuse me. That among clinicians who are burned out, patient care is affected and it shows up as errors, maybe less empathy for people that they're taking care of, perhaps reduce patient satisfaction and decrease adherence by patients to treatment recommendations. We don't quite know what mediates all of that, but we know that there is an association again, published literature, lots of it that's starting to look at what the so what the implications of this. We know there's a systems cost and I think anyone who is in a leadership role anywhere in this country and health care knows that turnover is an issue and it's really difficult to spend time really investing in individuals training them to your sister's alignment and values delivering good care, doing all of those things. And then to have them leave the profession for one reason or another. Um, and then there's also particularly a nursing, a lot of discussion about absenteeism. So people don't show up to work or present. He is. Um, you show up to work, you're really not able to do your full roll so your present but not real and productivity is affected. And then of course burnout matters. And this is a little bit of where we started. There's a personal cost to it as a personal cost both for the individual and increased risk of suicide which has been documented and people who are more burnt out but probably more common is dysfunctional relationships at home with people you care about. And some physical manifestations that it looks like. There's an association now in all of these particularly for some of these personal costs we have association. We don't have causation. It's really hard to know if you're somebody who has a mood disorder and things are worse. What where did that come from? What is it? Chicken egg. And in some ways doesn't matter and how it matters for trying to figure out what the best intervention is and that's why I bring this up. It's just really saying that burnout matters not only at the level of the individual experiencing it but for the systems in which we all practice and for our patients. Now if you're having questions as I'm talking to you about this or questions about the data just hold on to those and we will leave plenty of time for Q. And A. And we can come to that and I can tell you certainly national data and I'll lena my colleagues here to give you any local flavor to what we know and what the experience is. And more importantly, um, the strategies that people have been putting in place to address it. Um, super wonky slide, There are two points I want to make for you, one that there is at the highest levels nationally. This is the Academy of the National Academy of Medicine. This is where the first studies get done about, Gosh, inequality isn't what we wanted to be. How do we address it? While the National Academy magazine started this work in 2019 and it's the clinician wellbeing study and this slide really just says we recognize that there are many different things that go into getting to this right hand side of slide, this outcome slide around clinician burnout and recognizing that the, the other side of it, what we want burnout is like when things are not going well but the well being is so we want to look at both of those things. Those are the outcomes and it has consequences in the way that I've said for you here, I didn't talk about society but we can imagine there are consequences for everybody when things are not ideal in a system and when they are ideal ng system. Okay, so all good and well and then killed it happened and people that were already feeling quite burned out. And yes, this is a bit of a dramatic slide, it's intended to be right. It's intended to say for some people, this is what it felt like, felt like they couldn't control enough things And we all had a huge amount of uncertainty just not knowing how long this was going to go on. Um, did we have access to the equipment, whether it was PPE or ventilators in different parts of our country? We've been incredibly fortunate in the Bay Area because we have not experienced the extremes that other places have and are experiencing now with the fourth fate, fourth wave of delta through um, some of what happened with Covid is that in some systems, people got redeployed, you might be a palliative care physician who's now doing inpatient error. Um, and that created its own set of stressors with it. Um, and hopefully getting enough training to do that. And of course the worry about taking something home if you're exposed in a work environment, what might that be like? And so I think I would say really, particularly in the area, which I know best. The vast majority of our systems have really risen to exactly where they needed to be, to support their clinicians and to support others who are part of the lives of clinicians and really just thinking about consequences and how to prevent those and mitigate them. And a reminder this was national news and has continued to be, these are both are taken from the new york times, which is one of many places you can find this, it just had the the best photographic at work to translate to a slide. But lots and lots of conversations, a lot of anecdotes mostly about doctors and other members of the health care profession facing growing up and how are they managing, what were they doing for self care, what were they doing to recoup and in some cases um why they were chose choosing to be on the sidelines and perhaps not wondering about whether or not they want to return to care in the same way that they had been practicing. Did I want to go to bed back to bedside nursing? Did I want to do you know, I see you care, that kind of thing. All right, so I showed you in a moment ago this National Academy of Medicine slides And the work that they started in 2019, they have continued to take further out to really help define what do we actually mean? What are the factors and why do this? The reason we do this is we're looking for solutions, we're all looking for solutions for where we can have the greatest impact, which areas make sense. What where is the evidence in this? If you're going to make an intervention at a personal level or a team level, well what is that? What's the evidence for it? And so the National Academy did this and I want to tell you a little bit more instead of just seeing these little um diagrams here, what does it actually mean? So look at the one on the, like the four o'clock where it says skills and abilities. So those are individual level ones examples might be, what's your clinical competence? What do you know? Where are you in your degree of empathy? Are you depleted or repeated? And what are your abilities and skills around teamwork? Those matter in affecting burnout on the personal factors. These are these combination of things like what's your social support outside of work? What are your relationships like the quality of those um in work or outside of work and perhaps personal traits or predisposing factors that either make you more resilient because we know that some people are individually more resilient or they make you less resilient. So those are important factors. I'm going to switch gears and look at the learning and practice environment examples of that or is there mentoring around with that seems to have a positive effect on allowing people to feel, have a positive sense of well being, the ability to learn to grow and you're the quality of your professional relationships. Some examples around organizational factors might be this diversity, equity and inclusion, which has gotten a huge amount of um interest in responsiveness from all of us, given everything that we have experienced as a society in the last several years, but last year particularly. Um it might also be the mission of the values that drove you and drew you to work in the organization that you work in. So those are examples and then the last one will touch on is health care responsibilities, things that go into this category are, What stage of career are you at? Are you early in your career? Are you later in your career? What's the population of patients you take care of? And what's your sense of affinity for the conditions that you're treating? Those kinds of things? So you can see this was intended to be almost all encompassing, which can make it really challenging because there is no way that any one person is always going to be balanced on personal factors or abilities or skills and there's no way that any system or organization can always be balancing me all of the criteria ideally. Um, and you can see some of these criteria are outside our institutions right there. Society and culture and rules and regulations that we all work in well. What about wellbeing interventions? What do we know about those? And I'll tell you the high level takeaways, we know less but we know some. So what I've tried to do on this one slide this is probably the last 10 years or so of what the takeaways are from the literature when an intervention has been done to improve well being and these are the things that most people have focused on most has been around stress reduction programs. There might be as um defined as mindfulness based stress reduction, which we certainly talk about, it might be cognitive behavioral therapy, it might be coaching. There's been quite an array depending on the system in which it was occurring, the resources that they had access to and what they thought was going to be the most meaningful intervention to help with stress reduction. And um and then some in a few programs they looked at educational training and skills and most of them have actually focused on communications. How do you have difficult conversations? How do you address conflict and those of them what the skills of training and what most of these studies show when they measure levels of well being, but they measure levels of burnout is that there is a benefit from these programs. It varies what the degree of the benefit is. Most of the studies just do before after and a few of them have gone to do further out. So like what happens three months after what happened six months after. And what we find in the few studies that do that is the benefits from programs like this can be sustained for a few months. We don't know that doesn't mean that can't be sustained longer. It's just that as far as the study went, was just to look maybe six months out to say did the benefits stick And we have, we're just starting, I would say we're at the baby steps of evidence and solid evidence for interventions that are really around the teens and around systems of care and when I say systems of care, I don't necessarily mean large systems. I mean it can be whatever the key group is um or it can be even die abs so the ones that have been tested and um looked at have been um looking at redesign of workflow, um looking at what happens, do you get benefits when you have people working in diets or cares or if you expand who the team members are adding in different groups of health workers into those teams, I will tell you most of these studies have been done in really large systems because it takes a ton of resources to put many of these in place and to sustain them. Um and these have been sustained Schwartz rounds which for those of you that know about them are started mostly in boston but these are really, they're kind of like a grounds round style but with a different focus, it's not the sage on the stage, it was, we often say it's really getting an entire group that might have participated in the care of somebody where there was either a good outcome or a bad outcome and really but there was an emotional component to what happened, so a really common example complicated death, a complicated illness, a complicated hospitalization and it is a chance instead of for people to have to individually think about what happened and how do I feel and if I processed everything I think or my contribution or a mistake maybe I think I made to do it with a group and to do it really is part of a process of healing. Um and so it's usually a multidisciplinary group that comes in, it's facilitated. So it's not um it has a structure to it. People share their experiences and and that's a discussion and a chance to open it from comments. Those studies have shown actually this helps people with well being, because perhaps because it gives us room to actually do the processing, perhaps because of support, because you're doing it in a large and often again it's really literally done like grand rounds. It's an auditorium full of people who have been somehow involved in care or interested in the topic. The last ones. Um you can see some of them are just great examples of the subscribes or duty hours or doing quality improvement in your practice. And then I have one that's in quotes and it's and it sounds rude but it's really, I wanted to tell you about this one study that was done. It was really interesting. Was called getting rid of the stupid stuff. It's written up in the new England journal, not a simp and what it really was an effort that came out of hawaii and they said, you know, our our teams and this was all levels are complaining about various things that are just a source of regular frustration. So what if we could quote, get rid of the stupid stuff, what would happen? What would it look like? What was interesting about the study is that they ask people to just say, give us your, give us all of your, um, things that bother you in the course of a week and we will try to look at these and we're going to bend them and they put them into three bits. One business signup. Sorry, I know that really is not ideal, but that's a regulatory issue. That's a licensing issue that we're going to have to maybe figure out a different way around. But that is sort of, we can't, there's no work around. So that, that was one bit, it's like, yeah, we got to do it. It's regulatory. The second one was we ever worked full of thing this weekend change. And the third is the, I don't know why we do that. Like it got built into a system, but we don't necessarily know why we do it. And so they were able to take about a third of those and just able to clean them out and say we're going to task a team and we're just going to work through these and we're gonna put them in a bin and you're going to know which one they're in and the ones we can get rid of and what they found is not only did they streamline some things and improve some efficiency. Um at least in the, in the time that they were doing the study, but they were able to just get a much better conversation going about. If you see something that doesn't make sense highlighted because perhaps there's either a good reason for it and we haven't explained that reason to you or we should look at that and see if there's a different way to do this. So interesting study, it's been um an issue that the american College of Physicians has picked up and said perhaps we should look to see how might we help other places look at this and do this. Um does it improve well being? Well, no one's really measure that, but it seems like it's one of those like seems reasonable, it seems like the right thing to do, but again, a lot of work because these are at early stages, but things that people have tried and tried to report on like do these help with well being all right. So I'm going to just stop for a moment because I have given you in some ways this academic, which is partly what I was asked to do about an academic tour through burnout and well being, which is yes, it exists. Yes, we're seeing patterns that are worrisome to all of us and yes, there's efforts going on to try to find ways to improve them and mitigate them and to shift from focusing on burnout to really focusing on well being and what well being means and how do we achieve that. Um and so I want to I want to end with, so if you're uh if you're like me, you like sort of those ideas and those concepts and linking them together and they get you thinking about other ideas and for some people that's just like that's really great. But what does it actually mean? Like what can I do? So I'm gonna I'm gonna end with two slides and then we're gonna open it up, which is what can you actually do? So these are these are you're going to look at them and you're gonna take your own assessment of them. They come from both, I would say some practical experience and then also what's what's available in the field. The first thing is any time we're feeling this and maybe this gets back to me And my sighing when I was really having that period of time where I was definitely having some burnout was just great. Really just step, physical act of breathing and relaxation really helps. And it helps with some of our Dublin ergic responses as well. So just there's a good neurochemistry and didn't get into that here, but there is actually some really good evidence, there is a value as there is in many other settings to acknowledge how you feel and to name it not to dwell in it, but acknowledging it is first part of it. If you deny it, if you don't believe it, like I didn't for one time I was like, I'm not the kind of person, I don't get burned out, I'm incredibly resilient and the reality was a knock always. Um and so just acknowledging it so that I can address in um these are some practical things that actually really help we know that social connections, however they show up for you, whether it's charting in the same room as somebody else, whether it's curb citing to us, your colleague for what would you do in this situation, those kinds of connections both around work and uh in pre covid times coffee together a meal together, these things matter and they actually have um acknowledging and perhaps I think I needed to do this for myself and just be kind to yourself or days you're just gonna, you're not having the best day, acknowledge it and try to move on and support the others around you when there also might be having one of those difficult moments and we'll come back hopefully better the next day or in a short while reminder to make time and space for well being. Uh and that really looks different for different people, some for some people it's exercise for some people, it's coffee for some people, it's disconnecting after a certain hour, whatever that is for you just leaving time for that. There is really good evidence that learning something new. It does not need to be about work. Um, whatever that hobby is or something else that really activates a different part of your brain actually helps with well being asking for help. I will say this is the thing that I did not do well until I just really sort of realized like, man, I can't, I can't like talk my way out of this or intellectualize my way out of this was like okay, I just need to figure out. So for me asking for help meant let me figure out like a better way to do this. Clearly I'm spending too much time on this or I'm frustrated by something that doesn't make sense. Like help me recalibrate, help me just like view this a different way and so doing that with trusted colleagues because it isn't always feel safe to do that with the random person. But I I'm confident that you have people whether it's in a professional setting or in a home setting where you can turn to and say okay, I just need to either talk out loud about this or need some support and help coming up with a plan. Um, and it sounds cheesy, but I have reminded myself that sometimes I just really need to embrace joy when it's present and not minimize it. You're like, yeah, that's great and then move on. Which I think we often tend to do. Um and then I want to end with this lab slide and it talks really about, well what do you do as leaders? And I want to be really clear about what I mean by leaders. To me a leader. Is anybody who is working with a group of people? You may not have a title. You may not have a position. But in my world that is the definition is that you are leading something. You have agency in spaces, you have an opportunity to do things and there are people who are turning to you for direction or guidance. So if you think of yourself in that way I have a shorter list for you because I can make it longer. But I think you will add to my list. Don't ignore it, ignoring it does not make it go away. Um and so if you see that in one of your team members, if you see that in the medical assistant you're working with, you know make room and pause when you can to give space for it. Perhaps they need to voice it. Um committing to making space to talking about it without shame, blame or any of those things. We attach emotions very quickly to this. And as I said to you, like you know, I had a vision of who I thought I was and how I showed up in the world and it didn't feel good to say oh I'm not that resilient always. Um but making room for other people to talk to them for other people to normalizing it for me really helped those were the leaders that I was turning to. Um as a leader. I think one of your obligations is to look for and ask for ideas and solutions now if you're the person offering a solution no that not every solution or idea can be acted on. Doesn't mean it shouldn't be heard but know that it doesn't mean it will all be enacted and that get rid of the stupid stuff was I think a great example of that sometimes they're there for a reason the things that we have to do and but but that can be explained to you also um support connection and recognition. We have tried in our practice to do some small things just around whether it's a birthday recognition for like whose birthday is that month to recognition for a job, well done patient care delivered with incredible empathy or skill. So however, that gets called out, sometimes it's emails that we trade just recognizing somebody and sometimes it's more formal. Um, as a leader, particularly positional leader, I think have all taken on this responsibility seriously which is measuring and monitoring it. No one believes it doesn't exist well being and burnout and I think that I will say I suspect your experience will be similar is that I have to commend the people that I work with and that I have seen in action um that they are they understand it. There is not easy solutions, but there is a commitment. And the last thing I'm gonna end with is right here, this is a chief wellness officer from the East Coast that I worked with on this as part of the study was interviewing her and and I just thought this was such a great quote like this is not we did not want to be heroes, but we want to practice with Grace, energy and humanity.