Establishing Clinician Well-Being as a National Priority
July 15, 2017 Meeting Summary
In his opening remarks, Victor Dzau, President of the NAM and chair of the Action Collaborative on Clinician Well-Being and Resilience, highlighted the multitude of factors that drive clinician burnout, a syndrome characterized by emotional exhaustion, depersonalization (ie., negativity, cynicism, and the inability to express empathy or grief), a feeling of reduced personal accomplishment, loss of work fulfillment, and reduced effectiveness.1 These factors include stigma and fear of vulnerability, the regulatory environment, the digital health environment, organizational leadership, the learning environment, and a culture of silence that exists across the profession.
Dzau urged the audience to share in his vision for the future, one that implements evidence-based solutions, leverages networks of organizations committed to improving clinician well-being, grows that network to create a national movement and a unified community of empowerment, and promotes a campaign of systems-level change to improve the overall culture of clinician well-being.
Marc Moss, Roger S. Mitchell Professor of Medicine and Vice Chair of Clinical Research in the Department of Medicine at the University of Colorado School of Medicine and President of the American Thoracic Society, focused his keynote remarks on the ‘silent’ epidemic of psychological distress in critical care professionals. In particular, he highlighted research that examines long-term psychological distress in intensive care unit (ICU) nurses. He argued that the ICU is an inevitably stressful environment because of the high rates of morbidity and mortality, the complexity of ethical dilemmas, and the constant experience of traumatic situations. This tension-charged atmosphere, he said, can result in healthcare professionals suffering from burnout. According to Moss, often times, burnout results in higher rates of nurse turnover, which are associated with decreased quality of patient care, lower patient satisfaction, an increased number of medical errors, increased rates of health-care associated infections, and higher 30-day mortality rates. Nurse turnover also has a negative economic impact on hospitals because of the high costs associated with nurse replacement.
Moss offered promising interventions to improve the well-being of ICU nurses. He explained that therapies which enhance both the work environment and improve individual resilience are more effective than either approach individually; however, there is more data on individual resiliency training. Resiliency is a set of individual skills, behaviors, and attitudes that contribute to personal physical, emotional, and social well-being, including the prevention of burnout.2 After performing several research studies, Moss and his colleagues acknowledged that resiliency can be learned, which led to the development of a mindfulness based cognitive therapy (MBCT) program for critical care nurses. This intervention incorporates mindfulness skills, cognitive behavioral therapy, and interruption of negative thought patterns. Moss and colleagues are in the process of adapting and pilot testing this program.
In his remarks, Sandeep Kishore, Associate Director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai, gave a powerful introduction to the NAM Perspectives series, “Breaking the Culture of Silence,” by reading a suicide note left by a medical student. He shared Kaitlyn’s story to highlight the deepest tragedy that can result from burnout, connect it to his own personal struggle in medical school, and empathize with others who may be dealing with similar situations. He encouraged people in the audience to share their story as a way to build a movement against the culture of silence that exists in the medical profession.
Kishore then introduced the four working groups of the action collaborative and facilitated a discussion about their mission, goals, products, and progress to date. Updates from each working group are summarized below.
Research, Data, and Metrics
Steve Bird, President-Elect of the Society for Academic Emergency Medicine and Robert Harbaugh, Past-President of the Society of Neurological Surgeons, explained that the mission of the Research Data and Metrics working group is to positively affect health care delivery by promoting the well-being of health care professionals at the individual, organizational, and systems level through critical analysis and synthesis of published research and the development of a research agenda to address evidence gaps. Participants in this working group are focusing on several products, including a list of survey instruments with reasonable validity and reliability that can be utilized by investigators in the field to measure clinician burnout and well-being and an annotated bibliography of individual and organizational interventions examined in recent systematic reviews. In addition, the group plans to outline the research necessary to determine the true human and financial cost of burnout and improve clinician well-being, and to determine the support needed to accomplish this research.
Lotte Dyrbye, Professor of Medicine and Medical Education at the Mayo Clinic, provided an overview of the existing research on clinician burnout, drawing from the recently published NAM discussion paper, “Burnout Among Health Care Professionals: A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care” (Dyrbye et al, 2017). In the paper, the authors provide data that underscores the higher rates of burnout among physicians, medical students, and residents as compared to the general public. The authors highlight a bi-directional relationship between burnout and patient quality and safety, showing that higher levels of burnout are associated with an increased probability of reporting a medical error, which is in turn associated with worsening levels of burnout and depressive symptoms. The paper concludes with three major areas for future research that can advance the field of clinician well-being and patient care:
- Exploring the organizational and health care system factors that contribute to distress and threaten well-being,
- Analyzing the implications of distress and well-being on health care outcomes, and
- Performing intervention research to improve the work-lives and well-being of health care professionals.
Tait Shanafelt, Professor of Medicine and the Director of the Program on Clinician Well-Being at the Mayo Clinic, commended the progress made by this group and expressed that the anticipated deliverables will help advance the field. Shanafelt encouraged researchers to pivot towards intervention research and partner with experts outside of the health care profession, such as systems engineers, design thinkers, organizational science specialists, and business leaders. He also warned against oversimplifying a complicated problem that consists of a variety of individual, work unit, organizational, and societal level factors that cannot be solved with a “one-size fits all” intervention.
According to Arthur Hengerer, Chair of the Federation of State Medical Boards and Lois Margaret Nora, President and Chief Executive Officer of the American Board of Medical Specialties, the mission of the Conceptual Model working group is to create a comprehensive conceptual model that identifies, defines, and communicates the factors affecting the well-being of health care professionals, and promotes solutions to improve individual, organizational and systemic well-being to positively affect health care delivery. Upon review of many conceptual models addressing well-being and burnout, this group created an all-encompassing conceptual model that reflects the factors affecting clinician well-being and resilience (see Figure below). Domains include external factors such as societal drivers, organizational factors, the regulatory environment, and the learning and practice environments; and individual factors, including healthcare role, relationships and social support, learned skills and abilities, and personal factors.
The group is following an iterative process to continually shape the model and is exploring whether to add layers to the model to reflect evidence-based prevention and therapeutic interventions. Hengerer and Nora added that the group will create a common taxonomy for the Action Collaborative and publish a series of discussion papers outlining the process of drafting the model and addressing specific domains.
Matthew McHugh, The Independence Chair for Nursing Education; Professor of Nursing; and Associate Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, provided a reaction to the presentation of the conceptual model. He applauded the group for differentiating between individual and external factors and ensuring that the model contains all of the elements that comprehensively describe clinician burnout. Moving forward, he advised the group to focus more intentionally on the external factors, illustrate the relationships between the domains more clearly, consider the multilevel manner in which burnout can affect outcomes, and discern the comparative importance of each factor so that they do not inaccurately carry the same weight, as the research suggests.
External Factors and Work Flow
Pamela Cipriano, President of the American Nurses Association, who co-leads the working group with Cynthia Daisy Smith, Vice President, Clinical Programs at the American College of Physicians, shared the mission of the External Factors and Work Flow working group, which is to address individual and systems level factors that affect the clinician working and learning environment, and promote solutions to improve individual, organizational, and systemic well-being to ultimately improve health care delivery. She outlined the two priority areas of this working group:
- Provide recommendations that will reduce the administrative and regulatory burdens across the entire healthcare team
- Articulate the rational for and provide evidence-based interventions for implementing high-functioning teams that work well across silos of care, decrease isolation, and promote the best and highest use of all personnel.
Participants in this working group are developing a series of discussion papers that will focus on these topics and will integrate information from an enhanced table of drivers of burnout and engagement among health care professionals that was developed by working group participants.
In response to the presentation by the External Factors and Work Flow working group, Doug Fridsma, President and Chief Executive Officer of the American Medical Informatics Association, suggested that because regulations are created for practical reasons, it is important to modify existing regulations to better suit today’s learning and practice environment rather than call for their elimination. He advised the group against using technology haphazardly, suggesting that they instead deliberately apply its benefits as a positive tool that can promote high-functioning teams and embed resilience at a systems level. He provided two critical next steps for the group: consider the costs and benefits associated with a systems-level intervention and use that metric as a way to guide decisions; and recommend an evidence-based intervention that will reduce administrative and regulatory burdens.
Messaging and Communications
As stated by Neil Busis, of the American Academy of Neurology and Clif Knight, Senior Vice President of Education at the American Academy of Family Physicians, the mission of the Messaging and Communications working group is to coordinate, collate, and organize the products of the working groups, and provide consistent messaging across the collaborative to incite collective action among stakeholders. To achieve this mission, working group participants have developed key messages and messaging principles for key stakeholders needed to invest in the issue of clinician well-being. These groups include:
- Key Decision Makers and Systems-Level Influencers,
- Health system leadership
- Educational and Accrediting Institutions
- Specialty Organizations
- Health IT Companies
- Health Care Professionals,
- Practicing clinicians
- Learners, including medical students and residents
- The Public
- Clinicians’ loved ones
The group places the patient at the center of their messaging, reasoning that the well-being of health care professionals is a patient safety imperative. The group is also responsible for creating a knowledge hub, a website that will act as a repository of resources developed by the collaborative; existing research on the topic of clinician well-being; and resources for individuals and organizations to improve clinician well-being at their own institutions. A comprehensive online repository of resources will be available in early 2018.
Orly Avitzur, Medical Director of Consumer Reports and Editor-in-Chief of Neurology Now, provided her reaction to the Messaging and Communications presentation. She advised the group to focus the messaging of the Action Collaborative on the interconnectedness between the health and welfare of healthcare professionals and that of the public. She highlighted the importance of reframing the problem in a way that is comprehensible to the public and placing the patient at the center of the discussion.
In a session moderated by Darrell Kirch, President and Chief Executive Officer of the Association of American Medical Colleges and co-chair of the action collaborative, meeting participants provided feedback on the progress and direction of the working groups. Kirch offered a powerful parallel between the National Academies report on quality and safety, To Err is Human, and the current work of the Action Collaborative. This report, Kirch explained, corrected the presumption that the levels of quality and safety in health care delivery were already at their highest because health care professionals were the best trained personnel using the most effective technology in the field. Similarly, the work of the Action Collaborative aims to unearth and rectify the presumption that health care professionals can and should cope with the stressors involved in delivering clinical care.
Public participants provided their feedback on individual factors that can improve clinician resilience, external factors that should be assessed to advance the field, organizational and systems-level interventions that can promote culture change, and far-reaching partnerships that must be forged to build a national movement. More specifically, they highlighted the importance of studying the factors present in clinicians who do not suffer from burnout, stating that certain patterns might provide insights that could be reinforced by individual clinicians to improve resiliency. Public participants suggested that the Action Collaborative focus on two key external drivers moving forward: fundamental payment reform and documentation reform that prioritizes outcomes rather than process. They emphasized the urgency of creating and assessing the impact of organizational and systems level interventions rather than individual resiliency programs, arguing that these higher-level programs will support broader culture change.
Finally, several participants encouraged the Action Collaborative to engage patients and consumers during every step of the process. They argued that partnering closely with patients and consumers to discuss patient-centric issues regarding patient safety, medical errors, and improving clinician-patient communication will not only increase patient satisfaction but also will have a positive effect on clinician well-being. They also recommended engaging systems-level decision-makers within the business sector, such as private equity groups and larger publicly traded companies, to broaden the discussion and create true culture change.
Michael Rabow, Director of the Center for Research on the Healer’s Art and Professor of Clinical Medicine and Urology in the Division of General Internal Medicine at the University of California San Francisco (UCSF) School of Medicine, presented the medical school physicianhood and values curriculum, the Healer’s Art. Founded at Commonweal and UCSF by Rachel Remen, this curriculum is now offered at 113 medical schools around the world. It was created to strengthen students’ highest values and thereby protect against the “hidden curriculum” which might lead to professional deformation. This unwritten, unspoken code dictates how medical students should behave and forces them to sacrifice certain character traits and personal aspects to perform well in medical school. The Healer’s Art builds resiliency and commitment by bolstering students’ core values, rooting them to their deeply held moral code as a way to maintain their humanity, compassion, and ability to serve. By creating a safe environment for medical students to explore and commit to their core values, the Healer’s Art reaffirms each student’s purpose, stated Rabow. It consists of a series of five sessions in which students engage in a “seed talk” or a discussion with a practicing clinician, an “experiential process” in which students draw, think or reflect on a topic, and “small group work” with a faculty facilitator to continue the discussion and reflection. View his presentation >>
Cynda Rushton, Project Leader of the Mindful Ethical Practice and Resilience Academy (MEPRA); Anne and George L. Bunting Professor of Clinical Ethics at the Berman Institute of Bioethics and School of Nursing; and Professor of Nursing and Pediatrics at Johns Hopkins University, discussed the mission, goals, and preliminary results of the MEPRA program. The broad-based objectives of the program are to learn and apply mindful approaches to ethical issues in clinical practice, learn and demonstrate ethical competency by applying tools and skills to ethical issues in clinical practice, and cultivate resilience in response to ethical challenges and moral adversity by developing self-regulatory and self-awareness skills, moral sensitivity, and principled moral action.
MEPRA consists of six 4-hour experiential sessions that include daily emails with guided meditation and reflective practices, use high fidelity simulation to mimic complex medical experiences to develop self-regulation as well as resiliency and communication skills in a safe environment, and engage participants to leverage their skills to contribute to a culture that supports ethical practice. The immediate goals of the program are to strengthen one’s integrity, build skills to self-regulate in the midst of complex environments, cultivate empathy and perspective taking, recognize assumptions and biases, and learn effective communication skills. This intervention has been conducted with three cohorts, a total of 71 staff nurses. Preliminary data suggest improvements in work engagement, ethical confidence and competence, and resilience. Rushton’s team aims to integrate MEPRA into the Johns Hopkins nurse residency and educational programs, and has plans to create a larger MEPRA community to inculcate these skills in local units, building an initiative that promotes ethically grounded work environments. Rushton and her colleagues are also developing a moral resiliency tool that can be easily adapted by other fields. View her presentation >>
Jo Shapiro, Director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital and Associate Professor of Otolaryngology at Harvard Medical School, provided an overview of the Center for Professionalism and Peer Support. The mission of the center is to support a culture at the Brigham and Women’s Hospital that values and promotes mutual respect, trust, and teamwork. She discussed two of the programs offered at the center: professionalism and peer support. The first initiative aims to cultivate a culture of relational trust which is predicated on a high level of professionalism, defined as any behaviors that support trustworthy relationships. According to Shapiro, this initiative includes education for all physicians and other health care providers on how to manage conflict and to strive towards transforming unprofessional behaviors into professional, positive, and productive behaviors. In addition, the accountability process, in which those whose behaviors were repeatedly unprofessional, resulted in 83% of those who participated in the program being perceived by their colleagues as having either “some improvement” or “significant improvement” in their behaviors after undergoing the intervention. The Peer Support Initiative was created in response to the emotional impact that medical errors can have on clinicians. It provides team-based peer support, one-on-one peer support, and encourages proactively aiding colleagues who have faced an adverse event. This program promotes powerful culture change by normalizing emotional reactions rather than stifling them, providing a feeling of solidarity rather than isolation, and advocating self-care as critical rather than selfish. View her presentation >>
In his closing remarks, Dzau motivated the audience to partner with the action collaborative to create a palpable movement around clinician well-being. He encouraged participants to follow the progress of the collaborative, continue providing feedback, and work together to address issues of clinician burnout, stress, anxiety, and suicide. Finally, he reiterated the importance of including diverse stakeholders to alter the learning and practice environment and ignite revolutionary change at the broader cultural and systems level.