I’m (MK) joined by several experts, Dr. Daven Morrison (DM), Dr. Greg Couser (GC), and Dr. Andrew Brown (AB), all of whom are psychiatrists and published authors on burnout, to explore the crucial problem of physician burnout and how we can begin to address it.
MK: In your work, you talked a lot about ESG. Can you define that term and talk a bit about why it matters to this conversation on burnout?
DM: ESG is an acronym for environment, social and governance. Essentially, the environment is what are you doing to ensure that the planet is a healthy planet to live on. Are you actively looking to reduce your carbon footprint or doing something else along those lines to keep, basically, planet Earth healthy? The “S,” social, is more along the lines of race, gender, and issues related to DEI [diversity, equity, and inclusion]. How systematic, how thoughtful, how comprehensive is the organization around addressing that? And finally, G is for governance. How carefully, how thoughtfully, how comprehensively are you governing or managing your organization? The broader term that ESG is used interchangeably with is sustainability.
ESG was really motivated by the millennials in a lot of ways, asking questions about endowments, asking questions about, is there something more than shareholder value? Asking questions about, look at the boards of these companies, look at the makeup of who’s governing these organizations our university is invested in, look at what you say you’re about, look at what you’re actually about. There were several fairly progressive or forward-looking organizations that really targeted ESG in terms of their investments. And there’s a larger community of investors in ESG whose investments are fairly significant now … as much as $53 trillion.
And that brought me to the idea of H in between all three of them, the E, the S, and the G, is, “How are we thinking about the human being?” There are mistakes that are made because of burnout that harm patients. If there’s this energy, there’s investment in the scale of $53 trillion, could we introduce a dialogue between management and the physicians about monitoring and measuring burnout?
MK: How do we incorporate ESG into emergency medicine?
DM: I think that’s the natural next step of a dialogue like this. How do you build the case that it does make a difference to the proverbial numbers-crunchers, with the green-eyeshade-wearing CPAs. How do we build a case ahead of time before we’re at the desperate moment, and the hospital’s about to close, or they have to shut down different services?
How do we build that case [that] managing and monitoring burnout in ED doctors matters to the leadership? I saw this a lot in social media, that people were expressing angry sentiments like, “I do not want to come to another mandatory yoga class for dealing with my burnout at 6 a.m. in the morning. Seeing a stack of pizzas in the doctor’s lounge does not make me feel like the leadership cares.” Mitch, you and I know [a CEO], who does not ignore how the employees are doing. He is engaged at all levels. The guy that shows up to see what the employees are actually doing. He expects his leaders to get out into the hospital, get down into the emergency on the night shift and on the weekends.
MK: We as physicians and certainly in the emergency department are all familiar with metrics such as patients per hour or time to discharge and admission. It seems like we often jump from one metric to another. Is it a potential solution to expand metrics to administration to be accountable for burnout percentages as a countermeasure to physician metrics?
GC: I think you’re talking about the quadruple aim, and employee satisfaction is an important part of that. I think at times it’s sort of a Dilbert-esque management philosophy that pushes employees toward these metrics without fully considering their mental health.
DM: Carin Knoop, who directs the case writing department for Harvard Business School, has been writing and thinking about the importance of mental health in the workplace from the management perspective. And she talks about this catch that managers fall into, but physicians are particularly vulnerable to, is: The Hero. “I’m the only one. And when everything else fails, I will be there. I will show up.” So there’s this hero syndrome. Where we figure we have to do it all. They never say “no” to anything. And what ends up happening is they get worn down and by the time they realize that they’re worn down, it’s too late.
MK: It‘s a really interesting topic and also comes back to staffing. With this idea of, if I don‘t show up, who‘s going to replace me? And these days that‘s an increasingly big question mark in a lot of systems that struggle to have adequate staffing.
GC: That also gets back to the business case though, because you need to look at turnover. It’s six figures to replace a physician. Retention is important for organizations. And when turnover gets to a certain point and everyone’s leaving, that is when hospitals start closing. Organizations that figure out how to retain physicians are at an extreme competitive advantage.
AB: While they are not easy problems to solve, they are simple in the sense that we already know what drives people, whether physicians or other professions, to look for other work.
The first fact: A leader, and a supervisory staff more generally, that’s capable of establishing a personal connection with the people who work with them: That’s invaluable.
Secondly, we need to create workplaces where doctors and other health care workers actually like each other and enjoy each other’s company. Under such circumstances people look forward to going to work because they look forward to seeing their friends and colleagues there.
I would like to see medicine develop the kinds of peer support systems that the police have developed. In Boston, this has helped mitigate some of the impacts of public hostility. A culture of collegiality and mutual support would go a long way towards improving the work experience of physicians.
GC: The doctors’ lounge isn’t billable. There aren’t as many doctors’ lounges around [anymore] COVID changed that too. It seems like people are more in their offices than they used to be. it’s taken away from face-to-face contact. There are a few studies, one giving physicians time to get together in groups, and there’s an assignment to take a few minutes to talk about a burnout topic, but the rest of the time they get to spend with their colleagues. If they’re given time to meet counted as administrative time, it correlate[s] with decreased burnout.
DM: It also ought to be enculturated in the guild that we belong to, that taps into the idea of not only competition, but also perfectionism. I think those two come together. But perfectionism and hyper-competitiveness in particular can be a nasty blend.
MK: How do you find time to get together when your group of 30 docs is not all going to be there on the same day or you’re covering multiple hospitals? How do you find opportunities to do some of these interventions?
DM: It’s about “work and life-outside-of-work balance,” not work/life balance. If you mandate social gatherings, you may have somebody saying: “Well, I only want to work. That’s my contract with the hospital or the university. I just want to come in for work and that’s my deal. I’ll do work, you pay me. I’ll go home.” And then there’s the challenge as others are like: “Well, I want to know who you are. I want to have time together when we’re not working. I would like to.”
So, that gets to be a dilemma for management to figure out. Work is not just financial reimbursement. There’s psychological reimbursement. And if you’re only thinking about financial materiality … you’re going to miss the psychological materiality.
AB: The most important thing is that physicians feel that the organization cares for them. In police culture one frequently hears people say, “we’re a family.” What they mean when they say this is, “We care about you.”
If employers make authentic expressions of care and the intention to ensure that the physicians feel appropriately valued, it will show how to induce quality work. And people who come to work with a sense of mission don’t really need to be incentivized. The job isn’t necessarily how to create a set of incentives that will properly motivate the physician. The challenge is how do we subtract the problems that obstruct physicians and induce feelings of demoralization.
MK: Are there things that ER docs can do as individuals (not more pizza or yoga classes) to address burnout for themselves?
GC: There are some burnout models that can be helpful as far as individual solutions, such as the demand-control-support model. What demands do you have? Anything that takes up time is a demand. Is there anything that you could potentially get off your plate, anything that you could control? There’s going to be times that you can’t control things and that’s when spirituality, things like the serenity prayer can be helpful. We’ve got to be connected with people. We must reach out and be intentional about making sure that we have people in our lives. There’s the effort-reward [im]balance model. We expect to get rewarded for our work. And sometimes that means taking a look at our work to find things that maybe we do like to spend a little bit more time on.
There are things that we can pivot or change within our own work.
DM: I think the [social] fabric is important. This is more about just being a worker. One of the things that can happen as a worker is you can let social connections fade away, particularly men. And that shortens the life, it leads to more morbidity. And so, to be specific to people I know, especially men, “I’m not going to show up for the softball league,” or “I’m not going to go to book club.” They will say, “I’m too tired” or “I’m too busy.” And there are times when that’s reasonable, as Greg was saying, you have to be thoughtful about, “Should I be taking things off my plate?” or, “Should I also be making sure that I sustain those friendships and those social fabrics through the years?”
AB: Two basic principles are social connected-ness and physical exercise. If you can find a form of physical exercise that you enjoy doing, that can be enormously helpful.
With respect to the problem of burnout, sometimes a well thought-out, planned period of absence from work can do wonders. A few weeks or a few months off from the job to really try to process what one is experiencing, take some time talking with a therapist or another thoughtful person whom one trusts. Taking time to sort of recalibrate, reexamine. Ask oneself, “Why did I go into this profession in the first place? Why is it driving me crazy? Why do I feel so apathetic? Is there anything I can do about it?”
DM: One of the healthy coping mechanisms of being a physician is altruism: caring for others. For example, at the end of your shift, you’re leaving and that other doctor is taking on for you. And you can use your altruism for them: not to be prying and not to be rude, but as colleagues, you can check in with them.
I see this a lot in police and fire (and managers), the other sort of hero specialties or professions that they don’t really own up to how worn out they are until someone comes over and asks them. And then they’re like, “Holy shit, you’re right!”
Author’s Note: This interview has been edited for brevity and clarity.
Dr. Kentor is a board-certified emergency physician with an MBA from the Northwestern Kellogg School of Management in Evanston, Ill. He is a member of the editorial advisory board of ACEP NOW.
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