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Antidotes to Burnout: Fostering Physician Resiliency, Well-Being, and Holistic Development Herdley O. Paolini, PhD, Burt Bertram, EdD, LMFT, LMHC, Ted Hamilton, MD, MBA 19, 2013

A Novel Idea: Whole-Physician Care

Florida Hospital -- an Orlando-based 8-campus hospital with 2200 beds, a 2000-plus physician medical staff, and more inpatient admissions annually than any other hospital in the United States is home to Physician Support Services, a pioneering program created to address physician burnout.

The program provides whole-person care through specialized professional resources aimed at maximizing the personal and professional well-being of Florida Hospital physicians and their families. The direct financial benefit of the program to Florida Hospital is in excess of $5 million over the past 2 years, and the program has rescued the careers of more than 100 physicians in the past 10 years.

The service includes confidential psychotherapy and coaching, continuing medical education (CME) with credit that is focused on helping physicians integrate their personal and professional lives, dialogue programs about cultivating

meaning in medical practice, physician leadership development, and marriage retreats.

The Florida Hospital program is based on an in-depth and compassionate understanding of the forces affecting physicians and the practice of medicine, as well as the belief that physician leadership is crucial in envisioning and operationalizing the changes that are needed in the practice of medicine. Rather than ignoring, stigmatizing, or penalizing distressed

physicians, Physician Support Services pragmatically addresses the emotional, spiritual, family, and performance issues associated with physician burnout, while intentionally developing physician leadership.

Prevention and physician wellness must become even more robust and comprehensive as we continue this period of unprecedented change in healthcare. Changes in healthcare cry out for a more holistic and integrative approach to

developing physician leadership, changing medical staff cultures, and building stronger bridges of trust between

healthcare leaders and physicians.

Physician Burnout

During the past 20 years, many studies have documented the pervasiveness, symptoms, and root causes of physician dissatisfaction and burnoutJ1-4] Physician burnout, which directly affects quality of care, safety of patients, treatment

outcomes, patient satisfaction, nurse turnover, hospital staff morale, and financial performance, occurs at alarmingly high ratesJ5,6] As stated succinctly by Dyrbye and Shanafelt,!?] "Physician burnout is threatening the foundation of the US

medical healthcare system.

Despite ample evidence that depression, suicide, and substance abuse disorders are more prevalent among physicians than the general population, the mental health of physicians consistently receives low priorityJ5] This stark reality was dramatically brought into focus with the recent publication of the first national study of burnout among physicians in the

United States. The study explored burnout rates by specialty and compared physicians with workers in other fields, showing them to be at significantly greater risk for burnout. with almost 1 in 2 physicians experiencing burnout symptomsJ4j These findings confirm previous data showing that more than 40% of all practicing physicians currently suffer

or have suffered from burnout. and 45% of primary care physicians would quit medicine immediately if they had the

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financial means.l8]

Root Causes of Burnout

Physician burnout stems from multiple interrelated causes: excessive workload; loss of autonomy; administrative burdens

and consequent inefficiencies; ever-present litigation threats; decline in personal meaning from the loss of mitigating factors (eg, relationships with patients and colleagues); and difficulties integrating personal and professional life.

The culture of medicine. The root causes of burnout are thought to be exacerbated by a culture that can be compared with Hollywood's depiction of the American "Wild West," with its strong, silent, and self-contained heroes who never showed a hint of weakness. Part of the problem has to do with how physicians are trained. Medical school is a Darwinian grind,[9,10] compounded by high-stress residency that focuses solely on technical training without the professional

development needed by the new physician to navigate the complex intra- and interpersonal demands of current practice.l11 ]

Some will argue that physicians today are being trained in a more integrated way. Although that may be true in terms of what is seen on the explicit curriculum, it is not what it is often found in the implicit or "hidden curriculum." Like most of us, physicians learn what they see and experience, not what they are told.l12] This was illustrated by the widespread protests from residency faculty to the recently mandated reduction of resident duty hours to the equivalent of 2 full-time jobs.

The practice environment. The practice of medicine has become a complex business enterprise. Physicians expected long hours, personal sacrifice, and high demand. What they did not bargain for are the realities of today's practice environment. Front-line physicians spend a large proportion of their time doing paperwork and dealing with bureaucratic issues to care for their patients.l13] They practice in a highly litigious environment in which every patient they see is a potential lawsuit, mandating the unfulfilling practice of defensive medicine. The latest survey indicates that 60% of

physicians aged 55 years or older have been sued.l14]

Reluctance to seek help. Physicians often believe that they should be able to avoid depression, or just "get over it" on their own. Fear that a depression diagnosis could hurt their medical licensing is common, and many physicians appear to avoid treatment completely to protect confidentiality about their mental health.

The Florida Hospital Physician Support Services Program

The foundation of the program is 4 core beliefs.

• The well-being of physicians is a matter of national health;

• Physicians are human beings before they are rvIDs;

• The culture of medicine as experienced within the hospital should actively support physicians to be healers; and

• Physician leadership is crucial in promoting the needed changes.

From the beginning, Physician Support Services was envisioned as more than a place where troubled physicians could be

sent when their behavior became problematic. The mission, as articulated by Don Jernigan, then President of Florida Hospital and today CEO of parent system Adventist Health, was to create a service that was absolutely safe for, and respectful of, doctors -- so that doctors would access its services on their own initiative. It would be a place where physicians could grow and develop holistically, as well as a redemptive place to address their emotional and psychological

fears and traumas.

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In its genesis, the program was operated much like an employee assistance program (EAP), but one dedicated to

members of the medical staff. This "EAP model" languished with little utilization for almost 2 years before a new director was recruited. The new director, a PhD and licensed psychologist, decided that the best way to learn about the lives of physicians was to embed herself in their world -- to round with physicians, to scrub in with surgeons, to shadow physicians in their office practices, and to be there in the middle of the night as they responded to emergencies.

She also qualified for medical staff membership by working emergency department call schedules. She was determined to be visible in as many venues as possible so that physicians would come to know her as a human being and she would

come to know them and their world and language. In time, members of the medical staff began to trust that they were being heard and understood, and that what was discussed would remain confidential. Demand then grew rapidly, and the service now remains highly used -- with a waiting list for nonemergency cases. More than 90% of the physicians in psychotherapy at any given time are self-referrals.

Support Services for Physicians

Counseling and psychotherapy. Counseling and psychotherapy are available to all physicians and family members. Physicians come for counseling generally at their own initiation, but the servicealso handles referrals mandated by

behavioral issues.

On-boarding interview. As part of the credentialing process, physicians participate in an initial interview with a therapist. The embedding strategy offers a nonthreatening opportunity to establish a relationship between the new physician and the mental health professional. The therapist initiates a discussion about health and self-care practices, invites the physician to consider his or her professional development and future goals, and encourages the physician to tap into resources to support growth and development. Self-care is presented not as an option but as a best practice, therefore normalizing and integrating the personal with the professional.

The on-boarding interview introduces physicians to the physician support services program, as well as acting as a critical triage point for incoming physicians. The credentialing interviews have proven to be the single most important source of self-referral to the physician support services, responsible for more than 50% of clients seen in the program. Often, a physician will call to make an appointment for therapeutic services within 1 month of the on-boarding interview.

Executive coaching and consultation. Physician leaders benefit from coaching relationships at many points in their careers, in both the clinical and administrative arenas. Coaching services can improve performance, achieve better work/life balance, manage stress, improve health and well-being, increase interpersonal competence, and develop leadership skills. Coaching and consultation are particularly helpful when the physician is faced with challenging leadership or interpersonal tensions with patients, office or hospital staff members, partners or colleagues, and other healthcare professionals. The physician and the coach collaborate to understand the source of the problem, then design and implement trust-building, communication-enhancing, and conflict-resolving interventions to address the dysfunctional

situations. Consultation, a shorter-term interaction, is provided upon request to administrators and medical staff leaders

who face difficult medical staff issues.

"Finding Meaning in Medicine." Originally developed in the late 1990s by Rachel Remen, MD, these physician-to­physician facilitated dialogues invite doctors to speak from the heart about personal experiences in the everyday practice of medicine that remind participants of why they became doctors and encourage them to see their colleagues as people. These conversations enhance trust, goodwill, and collaboration among the physicians, which is a "win" for everyone -- the individual physician, the patients, and the healthcare system in which they function.

Physician leadership retreats. These retreats give physician leaders an opportunity to engage with peers as they

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increase awareness of personal styles, goals, and values in combination with a realistic and honest assessment of the

present environment of medical practice. It offers them tools to grow their own resiliency while gaining an individual and collective voice to engage the systems where they work and foster needed change.

Collegiality events. "Physicians in Concert" is an event designed to build a sense of community within the medical staff, while creating visibility for Physician Support Services within the community. These occasional concerts feature music performed by members of the Florida Hospital medical staff, providing them the opportunity to show another side of their talents and the audience a chance to enjoy some music.

Resiliency training. The daily demands of a complicated medical practice challenge providers to concentrate on the task before them, yet be able to recover rapidly and confront new problems and situations. Resiliency training teaches physicians to strategically incorporate into their lifestyles nutrition, exercise, self-reflection, mutually supportive relationships, and good health practices. Resiliency when confronted by adversity is supported by a holistic approach to improved overall health and well-being.

Results and Cost-Savings Analysis

A 2013 study calculated the direct financial benefit of the Physician Support Services program to be in excess of $5 million over the past 2 years in cost-avoidance alone. At the same time, difficulties involved in quantifying benefits, such as avoidance of revenue loss, reduced absenteeism, employee (particularly nurse) retention, employee and patient satisfaction, and other business and human resource measures must be acknowledged. l15]

More important, the program is credited with rescuing the careers of more than 100 physicians over the past 10 years.

We have long seen the link between the program's results and standard measures of patient outcomes, physician satisfaction, nurse satisfaction, and the quality of healthcare delivered by the institution. However, proving cause-and­effect relationships, although in theory possible, presents daunting obstacles in terms of the costs of data collection and analysis. The cost-avoidance metric, on the other hand, can be tracked at reasonable cost with a credible methodology based on the program's clinical data and the real costs experienced by the hospital when compelled to replace physicians. Although that metric will always underestimate the financial value of the program to the hospital, it more than justifies the

program investment.

Taking Solutions to the Next Level

Burnout has traditionally been seen as an individual problem, but in fact it is a workplace issue. The prevalence of burnout in physician populations, coupled with the leadership and interpersonal relationship skill deficits that are the legacy of medical school and residency training, have enormous implications for health systems. Clinical integration, patient and employee satisfaction scores, and the physician leadership needed for the transition to value-based compensation will

remain at risk until physician well-being and whole-person integration are addressed.

An effective approach must include:

• Treatment for physicians who are in need;

• An array of preventive initiatives for at-risk physicians;

• Opportunities for personal and professional development of the whole-person; and

• Perhaps of greatest importance, a program of sufficient reach and scope to catalyze change in the culture of medicine

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within the institution or system.

Principles for Success

An EAP-model crisis intervention service for physicians, however successful in enlisting physician participation, is insufficient. A more comprehensive program is needed, which supports the personal and professional lives of physicians in a longitudinal and holistic way. Furthermore, the program must develop physician leadership and a medical staff culture that can intentionally foster necessary changes in the way that medicine is practiced in the healthcare organizations to which they belong.

Seven distinct but interrelated principles and commitments are essential to successfully operating such a program:

1. Embedding with medical staff. The mental health professionals must became familiar to the medical staff by providing a series of outreach programs year-round. On-boarding interviews must be part of the credentialing process. The director should be an active member of the medical staff with call duties, participation at Medical Executive Committee meetings, and other clinical responsibilities. The embedded nature of the program provides visibility and normalizes participation in

the services.

2. Key working relationships. Relationships with physician leaders are formed through shoulder-to-shoulder work on medical staff-related projects and issues. Furthermore, relationships with administration are intentionally formed to facilitate mediation and advocacy on behalf of both the hospital and the medical staff.

3. Trust. Strict adherence to ethical practice in terms of safeguarding confidential disclosures will demonstrate the trustworthiness of the program. Under no circumstances can confidentiality be compromised. Segregated storage and other safeguards are essential to guard participant lists and case files from any breach or use outside the program.

4. Outcome reporting. Reporting proven outcomes is necessary to establish the competency and value of the program. Such reporting must go beyond activity measures (eg, number of clients, psychotherapy sessions, CME courses, and events) to quantify results in terms of mission, financial, and clinical impact. Measures, metrics, and data collection requirements should not be overlooked when allocating resources and setting budgets.

5. Stature. Practitioners must be trained at the doctoral level and be state-licensed and eligible for privileges. Obvious maturity, strong presence, personal integrity, and successful clinical experience in dealing with significant pathology are required attributes when working with physicians. Cutting-edge programming and professional attention to detail in preparation for events, workshops, and retreats demonstrate competence.

6. Knowledge of medicine and hospital business. Understanding the medical practice environment as well as business aspects of healthcare delivery is fundamental to interacting meaningfully with physicians and hospital administrators.

7. Champions. The service must be championed by both medical staff and hospital leadership. The active endorsement of medical staff leadership, as well as ongoing collaboration in shaping a culture that prioritizes physician well-being, is essential. Equally important is the support of institutional top management, without which the service loses its ability to

influence needed change.

Given the forces shaping the training and practice of medicine today, it is remarkable that so many of our physicians have managed to persevere in the art and science of medicine. Nevertheless, clinical data and experience are pointing to the dire consequences of leaving the wellness of physicians to chance. The program described here is a hopeful beginning in successfully enlisting both physicians and the organizations where they work in meaningful and positive change.

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For more information on the Florida Hospital Physician Support Services program, contact program director Herdley O. Paolini, PhD, LP.

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Medscape Psychiatry © 2013 WebMD, LLC

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Cite this article: Herdley O. Paolini, Burt Bertram, Ted Hamilton. Antidotes to Burnout: Fostering Physician Resiliency, Well-Being, and Holistic Development. Medscape. Apr 19, 2013.

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