"Who heals the healers?"
This is a question Barry-Wehmiller CEO, Bob Chapman, asked in 2019, long before the COVID-19 pandemic.
Today, the need for better leadership in healthcare has reached a breaking point. Healthcare professionals are suffering from burnout and other mental health issues and are leaving the profession in droves.
On this episode of our podcast, healthcare industry vets Paul DeChant and Bruce Cummings talk about their efforts to reverse the dramatic trends.
Transcript
Paul DeChant:
I currently work as an advisor to senior leaders in healthcare systems around the country on how to reduce the drivers of burnout in their organization, how to create a healthy place for their healthcare workers to work. And I came to this through 25 years of practicing as a family physician, during which time there were a lot of things that went wrong and I got into leadership because I wanted to try to fix those things that were going wrong. I eventually worked my way up into the role of the CEO of a 300 physician group in the Central Valley in California.
During that time, I was inspired to lead a transformation around a theme of returning joy to patient care and discovered that there were other healthcare systems around the country that were doing something similar, using lean actually, as their management system and culture, and not the way most people think of lean as, "Oh my gosh, this is an efficiency expert coming to tell us how to do things faster." But actually starting with respecting the people doing the work, because they know what's wrong and they have great ideas about how to fix it.
So, building on that over the course of five years, we actually got recognized as the top performer out of 170 medical groups across the State of California, two years in a row, by consumer reports. And had improved our physician satisfaction scores from the 45th up to the 87th percentile. So, we knew we were onto something. And I then left there and joined a consulting group that had helped us do this work and they sent me to a conference that Bob was speaking at. And I went to that conference, it was a manufacturing conference. I thought, "What am I going to learn from these manufacturers?"
And when Bob presented what he was doing to transform the human relationships and caring within Barry-Wehmiller, and shared the stage with five other manufacturing CEOs who had done similar things in their organizations, I came away realizing, this is what I actually had been doing without truly understanding it and really embarrassed for healthcare because while we a have a noble mission to care for people, we often are very harsh on each other, inside our organizations. And so, I've spent the last eight years now, really working on those concepts. I've co-authored a book about this and regularly blog speak frequently and had the pleasure of meeting Bruce a couple of years ago, to find a like-minded soul. And I'll let Bruce introduce himself from here.
Bruce Cummings:
So, I'm Bruce Cummings and I had a 40 year career as a healthcare leader at five different hospitals, three of which I served as a CEO for a total of some 27 years of that 40 year career. And I ended my time as a CEO, as the Executive Vice President in the Yale New Haven Health system and CEO of Lawrence + Memorial Hospital in New London, Connecticut, and of Westerly Hospital in Rhode Island.
When I retired, I traveled and took time to visit grandchildren and did a number of things that I had been wanting to do and unable to do when I was active as a CEO, but I continued to follow the literature and what was going on in the field. And as I reflected back on my 40 year career, I became increasingly concerned about and began to recognize that one of the things that few healthcare leaders really were grasping, was first, the extent of the burgeoning burnout problem among clinicians and the second, a near lack of understanding about the importance of leadership in tackling the burnout problem.
And so, unlike Paul, who's an expert both in lean and in burnout, I'd had experience with lean problem solving tools first at a hospital in Western New York, and then at my hospital in Connecticut, and have found it very effective, and as Paul points out, tapping the expertise of frontline staff, who would be able both to identify what were the worrisome problems in workflow and the work environment, but also coming up with solutions to deal with those.
And I was convinced that to tackle the burnout crisis required strong executive leadership and the judicious use of lean principles and practices, including the leadership philosophy, would be crucial to that effort. So, I began searching around the country to find an expert in both lean and burnout. And that brought me to discover Paul, I'm in the East Coast, he's on the West Coast. And so, as Paul said, we've been working together for the last couple of years to work with healthcare systems, to help them become more attuned to the role of leadership and of culture and the application of lean principles and practices to fundamentally change the workplace.
There's an article that appeared in the Atlantic Magazine in March of 2021, that I think aptly reflects our shared philosophy. The title of this article by Olga Khazan was, "Only Your Boss Can Cure Your Burnout." And so, that's what we're about, is to look at the ways of bringing human-centered leadership to the C-suite and working with healthcare leaders to help them tackle the burnout crisis.
Brent Stewart:
So, when you think about the medical profession, there's always the old image of the kindly, old country doctor who would make house calls and walk to your house when your kid's sick and things like that. And nowadays, it's almost like people see healthcare as these big, monolithic buildings. It almost seems like that kindly, old country doctor doesn't exist anymore. Is that accurate in the way maybe some people perceive healthcare? Is there some kind of truth in that, or is that just maybe overstating where we are right now?
Paul:
I think there's a lot of truth in that. There's been so many changes that have happened in the last 20 years, perhaps even 30, that have impacted the ability of someone wanting to be that country doctor. There's a small movement of people who are practicing what's called direct primary care, which have a similar practice to that, but the vast majority of healthcare is delivered now through large corporations. And the culture within those corporations has become a significant part of the challenge.
That the corporations formed in response to multiple external factors that have impacted us over these last 20 years. That old country doctor really lived their life, mostly in doing the things that provided them professional fulfillment, deeply connecting to patients, doing procedures that relieve suffering or save lives, educating other young doctors who are becoming their colleagues, or perhaps doing some research or innovation. But nowadays, we spend maybe a third of our time doing those things and two thirds of our time are caught up in administrivia, data entry, other things that distract us from that, because of all the factors that have come in. There's been technology changes, regulatory changes, insurance and finance changes, changes in demographics. All of these things have really impacted the way that medicine is practiced.
Bruce:
And Paul, I just had that, picking up on your question, Brent, that what I found when physicians would come to me, expressing interest in becoming employed is they would cite, almost every one of them, that they were trying to run a small business, as well as taking care of patients. And so, they were just being crushed by the weight of being a small business person and trying to stay on top of insurance regulations and multi-forms for billing, dealing with things like workers' comp, business liability insurance, things that no physician ever goes to medical school for none of those reasons, and rarely, if ever, actually learn about those things in medical schools. So, just running a practice became exponentially more difficult from a regulatory standpoint.
And then at the same time, payment models were changing. There was less money and it was being expressed in the form of fixed payments. So, that impelled a number of physicians in communities that I served, to literally knock on my door and say, "I love being a physician. I want to stay in the community. I simply cannot afford to continue to operate this way." So, that's these two phenomenon that I'm describing, the reimbursement pressures and the challenges of trying to run a small practice, impelled a lot of physicians to seek employment, either with a large group practice, like Paul ran, or in a hospital environment, as I did, but that of course, sets off a whole bunch of other trade-offs. Lesser autonomy, hospitals and group practices have their own bureaucracy to contend with. So, the setting changed, but a lot of the pressures and challenges continued undiminished.
Brent:
One of the things that you were talking about earlier is burnout. Is the burnout coming just from these financial pressures or the pressures of, like you said, trying to run a small business and see patients? Because it seems like the burnout is more severe now than it has been in the past.
Paul:
It definitely is more severe than it has been in the past. Certainly, the last few years of the pandemic have increased it dramatically, but prior to that, there were still significant issues. Probably a good way to understand burnout better is first of all, to understand what it is. It's an occupational phenomenon.
Burnout certainly is defined in the academics and through people like Dr. Christina Maslach, who was one of the pioneers in the field, she identified three manifestations of burnout. First is, exhaustion. When somebody's given everything they've got and they just have nothing left to give. Certainly, many doctors are experiencing and nurses are experiencing that now. Second is, cynicism. It's a reaction, once you've got nothing left to give, people start to protect themselves from their organization and even from their patients, by becoming cynical and standoffish. And then the third is a sense of inefficacy, like what I'm doing isn't really making a difference, which in some ways comes from those other two things. If we're disconnected and exhausted, it's hard not to feel like you're not making a difference.
And yet, in an interaction with a patient, the patient may be finding great value in the very same interaction where the physician or nurse is wondering if they're making any difference at all, which I think is unique and really a pretty sad situation. So, those are how burnout manifests, but burnout is the manifestation in an individual of dysfunction in the workplace. And Maslach also identified six key drivers in the workplace that drive burnout. And the first is work overload, particularly in healthcare now, we work in chaotic, time pressured environments, with information overload.
When we're overloaded, we experience a sense of lack of control and control's a big deal to doctors and nurses. We go through significant training so we can take control when that's needed. In fact, it's one of those intangible rewards we look for when we join the profession. And insufficient rewards is the third driver of burnout. Also, things like professional recognition and collegiality. We as doctors and nurses are nice people, we like to hang out with each other, but we've seen our ability to come together as a community, break down. And in fact, break down of community is the fourth driver of burnout, between physicians now working either in the hospital exclusively or outside of the hospital exclusively, we don't run into each other as much. And even if we're in the same room together, we're often typing away into a computer, interacting with the computer, not with each other.
The fifth driver of burnout is absence of fairness. Some of it's that sense that comes from all those other things I just described. But also as the clinical workforce becomes more diverse, there's many people who are experiencing being disrespected, not because of the contribution they make to their organization, but because of things they have no control over like their gender, their race, their country of origin, or their sexual orientation. And so, this is why DEI work has now become so important in organizations.
And the sixth driver of burnout is conflicting values. If my personal values conflict with the values of the organization I work for, or if I'm in situations where I'm caring for patients that I actually end up having to do or witness things that are in conflict with my values, which many people experienced during COVID, those are issues as well.
And just to wrap this up, what most people think of as burnout is, "I'm overworked and I'm exhausted and therefore, I'm burned out." But the other five drivers of burnout, that lack of control, insufficient reward, breakdown of community, absence of fairness, and conflicting values, those drive this cynicism manifestation of burnout. And that's where we have so much power to change the way we lead, because those are all dependent on leadership. And when we lead, we're tempted because it's such a chaotic, challenging environment, to lead with top down command and control approaches, but those only lead to further burnout. When we find a leadership approach which we know we can do, and which actually, Bob exemplifies, to empower and align people, that's where we can truly make a difference
Bruce:
Just to become more concrete about, how are those drivers manifest in a typical hospital, which is where my experience comes from. Certainly, the difficulties with the electronic health record that physicians and all other clinicians have to deal with, is a big problem area. Especially if it wasn't installed well or there's not good IT support, or there hasn't been an effort to do what's called optimization or remediation. There are certain interventions that can be undertaken to make that electronic health record work better.
The regulatory environment, hospitals are very complex and they become more complex every year with these extrinsically imposed requirements. And those ultimately trickle down to the front lines. I mentioned earlier about payment pressures or reimbursement models. These are constantly changing and there is less not more money, coming into the field. And then last but not least, specific leadership practices. Paul referenced the top down or command and control model that still is widely used in hospitals. All of these things taken together, create this very difficult work environment for physicians and indeed, all other clinicians to work in.
Mary Rudder:
Well, there's a lot clearly that needs fixing. My sense is that we cannot fix some of the problems, so we're going to fix the symptoms.
Bruce:
Well, that's a very thoughtful question there. I would turn that around and say, one of the things that led me to come out of retirement is I saw then, and I still see today, very conscientious leaders taking a look at what they believe the problem to be. And the solutions often put in motion are things like creating a position of a chief wellness officer and forming a physician wellness committee, or enhancing wellness benefits. Things like adding guided imagery or yoga or gym memberships. And our view is, these are pleasant, these are nice, but these do treat the symptoms, they're palliative in nature. They don't go to the root causes of what's driving burnout.
As Paul often likes to point out, the problem is not the worker, it's the workplace. And so, what we're trying to do really, is go to the root cause of those six drivers and make fundamental changes in the workplace rather than trying to treat the symptoms. This point of view that Paul and I are expressing, that the problem is not the worker, it's the workplace, is not widely known or widely appreciated yet in the healthcare field. And when we are engaged with clients, there is this kind of epiphany that occurs and we've gotten very good results, but this is not widely known yet.
So, Paul is really, a national and international expert, speaks widely, in fact, he's giving the keynote address at the International Physician Health Conference that's coming up in Orlando, Florida, in October. This is occurs every two years and is a combined effort of the American, Canadian and British Medical Societies. But too often, people who attend seminars like that, or conferences, are already true believers, they are those chief wellness officers or they're chief medical officers, or they're the presidents of medical staffs. They are not generally people from the C-suite. And so, that's the challenge is, how can we get this message in front of boards of directors, CEOs, and the CEO's direct reports?
Paul:
I get a number of people, particularly in medical schools, reaching out to ask me to present at grand rounds or something similar to that. So, I do a number of webinars, or I'm asked by a professional association to come and speak. We have more interest actually in just learning at this point than actually taking action. But the follow-up to deeply engage in the work is certainly much less common.
Brent:
So, what is it going to take then? I mean, right now we're in the middle of this thing that people have called the great resignation. I'm sure in healthcare in the last three years, dealing with the pandemic, that wave is probably there and coming. Because of the corporatization of medicine, is it going to take large swaths of physicians and nurses resigning, leaving, to get the C-suite to think about this? What's going to have to happen?
Bruce:
It's already happening and I think that that gives us a great sense of urgency to get our message out to more of the converted, because over 50% of physicians and nurses and other clinicians are reporting burnout. I don't remember the exact statistic, but it was something like 40% of nurses were saying they were going to leave the profession within the next couple years. And this is on top of an already existing nursing shortage.
So, the crisis is actually already here and there are no signs that it's abating. Yes, the coronavirus is less virulent and is better managed than was the case before. But these drivers that Paul is talking about, continue unabated. So, I've yet to see anything that suggests that this great resignation is in any way, diminishing in healthcare. If anything, it seems to be accelerating.
Paul:
Probably the only thing that's diminished that we would see it be much worse if it wasn't for the debt that people accumulate, particularly in medical school. Many physicians have $300,000 or more in debt when they finish their residency, before they've started their first day of their real job. Usually, these people are 30 years old or older, compared to their friends from college who went into the workforce pretty quickly, these folks, they have no home equity, they haven't bought a house yet. They're saddled with $300,000 in debt and they're probably just about time to start their family, where they're starting to have to put away money for all sorts of other responsibilities as well.
If it wasn't for that financial burden, I think we would see significantly more people leaving. The job is just, it's such a challenge. The lack of people quitting doesn't mean they're not suffering and miserable in their jobs. And many physicians are in fact suffering and pretty miserable in their work, particularly in the places where it is much more of a top down approach, where their superior will come to them and say, "We expect this level of productivity out of you. We expect you to now see this patients in an hour. We expect you to charge at these rates." And yet, aren't really afforded or provided the level of support that they should have for that.
We take some of the most highly trained professionals in the country, a GI doctor I talked to said, when he started his first real job, the day before he had graduated 26th grade, that's how long we go through training. And yet, these highly skilled people are then trying to deal with working with technology that is truly not user-friendly, where they end up spending two thirds of their time on data entry and other administrivia. And what other high-powered executive would be doing that? It's an absolute waste of time along with a waste of human dignity and meaning, and being.
The opportunity here is to actually, if we could flip that ratio of one third at a time, doing meaningful things that actually provide value, and make that simply two thirds of the time doing that, by redesigning workflows and improving technology, imagine the potential to increase access for patients, to increase the capacity that doctors and nurses have to truly focus on their patients, so people could get in and get seen more easily. It releases the capacity for us while we're at work, to much more meaningfully connect to our patients and to actually provide better care as a result.
That takes leadership to recognize indeed that this is the challenge and then to invest in the work it takes to redesign workflows. And health systems, for many reasons, some of which are, true financial health systems are incredibly strapped for the most part, these days. So, finding that money to invest can feel daunting. However, those who don't make that investment risk potentially digging themselves deeper into this hole. In the long-term, the healthcare organizations that are going to be truly successful are the ones that recognize this and respond to it by making those changes. Doctors and nurses will go to the places to work, that they find treat them with the respect that they deserve, give them the opportunity to do the work that they want to do. And the places that don't, that really just treat them as a line production worker, at some point, people will simply not be able to continue working there.
Mary:
I'm curious to know then, so therefore, you say that healthcare professionals, healthcare providers, frontline ones, are more satisfied, less burned out when they have more opportunity to provide direct patient care. So, does that mean, ER docs or emergency department physicians? Because the typical case that comes in the door is much more acute, so I would imagine the model there is that they are spending more time with their patients. I'm curious to know if those kinds of doctors are experiencing the same kind of burnout? Are there trends across different groups?
Paul:
So, there is variation from specialty to specialty, but it's not as great as you might think, except for some rare outliers, between most specialties there is somewhere between 40 and 60% of physicians are experiencing burnout. Now, you might say that's a 20% difference, but my gosh, 40% of people, even in dermatology are feeling burnout, that should be unacceptable, and yet, that's the case.
Bruce and I are actually working pretty closely with hospital leaders in safety net hospitals, and are focused on their connection to their ER physicians. And those physicians experience burnout, they're still having to deal with the electronic medical record and enter data into that record. They still deal with a lot of regulatory and administrative burden issues. The times that they spend deeply engaged in what's meaningful, still bring joy and that's why we do it, that's why people come back day after day. So, there's some variation by profession, but we see more variation actually, by organization. Even within these hospitals that we're working with, we can tell from the leadership, the differences in the levels of satisfaction and burnout in the physicians.
Brent:
The things that you guys are describing make so much sense and yet, those bigger issues are just not being taken care of. All of these severe statistics, dramatic statistics, why is this stuff not happening?
Bruce:
I'll take a stab at that. I think it's hard to really convey the extraordinary complexity involved in running a hospital. Peter Drucker, the noted management guru, who many consider the father of modern management theory and practice, observed some 30 years ago that hospitals were far and away the most complex organization ever conceived in history. And many of us look back and those were the good old days. So, the complexity has just increased exponentially over the arc of my career.
So, there are so many issues to juggle. There is so little time, there's little bandwidth. And certainly, the average hospital executive suite is aware of burnout, but because of all these many other issues they're wrestling, financial challenges, regulatory pressures, mandates, recruiting challenges, staffing issues, scheduling, compliance, equality and patient safety initiatives, patient satisfaction concerns. There's just not enough time to really concentrate on something as involved and difficult and multifaceted as this.
And so too often, what happens is this kind of reductionism or delegation where CEO said, "I know there's a problem. I don't know exactly what to do about it, but I'm going to create a position who will be responsible for dealing with this. We're going to have a chief wellness officer, because I've heard that's a good thing to do. And we'll create this physician wellness committee, because I've read that's a good thing to do. And then, we'll consider the problem solved. Next crisis, I'm moving on." And in reality, that's just the beginning, it's not the end. And so, that's part of what Paul and I are out trying to explain, is that this requires sustained, ongoing leadership and changes in leadership practices on the part of the C-suite. It can't be delegated.
Paul:
And there's a model for doing this effectively, that every hospital in the country has experienced in the last two years. When COVID hit, every hospital in the country created a command center that brought together all the top leadership to deal with whatever the challenges were, and they were multiple and ongoing and oftentimes, worsening. But two to three times a day, those leaders came together and learned what was happening, what was going wrong at the front lines and what they needed to do to sustain their frontline workers. And in the setting of that existential threat of COVID, we proved some things we didn't think were true.
First of all, we proved that healthcare could change quickly, when we used to tell ourselves that it couldn't, that it was too regulated, that there was too much at risk, and that we were unable to change quickly, but indeed, within a week we went from every doctor visit being in an office, in person, to 90% of them being through telemedicine. And we turned rooms we never thought could act as an ICU, like a regular hospital ward or a colonoscopy unit, into an ICU bed to handle the patients.
But as COVID, then the intensity of COVID decreased, the use of those command center meetings decreased. And now, while there's still this crisis of physicians being incredibly burned out, people ready to leave, ongoing suicide rates, we haven't really touched on that yet, but there's three to 400 physician suicides a year in the United States, from these issues. And all of that still is not considered enough of a crisis to maintain the level of intensity that those command centers provided us the ability to manage through the crisis of COVID.
So, we have a model to do this work, that model's there through the command centers. We just have not seen this as an urgent enough problem to put that kind of intensity to it. Now, we probably don't need to have command centers meeting twice a day to address burnout, but most command centers now, if they're meeting at all, are meeting once a week or once a month. And the organizations that will succeed in the long runs are the ones that take this seriously and have a far more intensive and responsive approach to addressing these challenges.
Mary:
Throughout all this conversation, we haven't even spoken about patient errors. Curious to know then, so what has been the impact of this burnout on the patient?
Paul:
There's a great doctor in University of Rochester, actually, a psychiatrist. He just retired from his active practice, but he's passionate about burnout and about how the human factors involved in how our care is organized and delivered, impact our ability to function. His name is Michael Privitera. And this work on human factors actually demonstrates that when people get burned out, they get less blood flow to their brain, there's anatomic changes that happen that decrease our short-term memory and increase our reactivity, and actually have an impact on our fine motor control, when you think about someone doing surgery. So, all of these factors impact our ability to really deeply connect, pay attention to, and be aware of challenges in caring for our patients. So yes, it does have an impact on quality.
Mary:
I would think that would show up in a hospital's performance scores. And that to me, is something that I would think the senior leaders would pay attention to, certainly the Joint Commission would.
Paul:
Mary, that's a great point and there's a growing awareness of that now, certainly in the agencies that regulate institutions in healthcare, whether it's the AAMC, which is the regulatory body for medical schools, the ASGME, for graduate medical education, and now Joint Commission. They're starting to pay attention to this and actually require efforts to reduce burnout or measure it and track it and work on reduction.
Bruce:
And I would just add, Mary, I think we've probably all seen that tongue in cheek sign that says, "The floggings will continue until the morale improves." There is a serious point here, which is that when hospital leaders see a diminution in a quality score or a patient safety score, the tendency is to redouble the traditional efforts. We need more documentation, better documentation. We need more reports. We need more oversight of those doctors and nurses. As opposed to stepping back and asking the question, "What is it about the work practices or the work environment that makes it difficult for these clinicians to get the scores that we think we should be getting?"
And so, go talk with them, find out what is militating against getting the kind of results that they would like to see, too. So, that's why Paul and I've used the shorthand expression about really looking at changing leadership practices. That to me, would be a very good illustration of that point.
Brent:
So, as we're wrapping up here, we've diagnosed problems, we have what we think could be a cure for it. So, where is the hope? Where is the hope that you guys are seeing going forward, and hope in what could happen, what could be, and what good things are starting to happen?
Paul:
Certainly, there is growing national awareness. The Surgeon General has come out with a few statements just in the last few months around burnout and actually is increasing his attention to this. The National Academy of Medicine has been focused on this for a few years and has just released ... Actually, no, it's just about to release, October 3rd, a new set of recommendations and focus on this.
We do see more discussions about burnout, either individual presentations within some other conference or more conferences on burnout, like the International Conference on Physician Health and another conference that Bruce and I have been involved with is a set of burnout symposiums that's now taking place every six months or so. So, there's growing awareness and in every hospital now, there's some focus on this, whether it's through taking the chief wellness officer approach or some other effort to focus in on wellbeing for clinicians. So, there is hope.
I think the thing that's going to spur action is when this challenge becomes significant enough that it's threatening the organization. There's so many other challenges that hospital leaders are dealing with, financial challenges, the threats of IT systems being hacked, you name it. That there are many challenges to deal with, but as this rises even more significantly as a concern, we're going to see more and more attention being paid to it.
Bruce:
I think hope springs eternal. Hospitals, for all of their complexity, can be adaptive organization. Paul used that excellent example of how during the height of COVID, command centers were set up and the seemingly impossible became possible because of exigent circumstances. And in a strange way, I think as this crisis burgeons, I think that will ... In a way, every crisis begets an opportunity and I think thoughtful leaders and boards of directors will be increasingly stepping back and saying, "Okay, we clearly need to do something different. And what is that?" And I think thanks to Paul's work, both his speaking and his writing, there is a pathway forward for those organizations that want to do something differently.
Mary:
I guess another glimmer of hope is that med school admissions or med school applications are up. So many people are still applying to med school, so there's still a lot of idealistic people out there that in spite of what's going on, want to become physicians and take care of people. And so, at least we have that to give us hope as well.
Paul:
You're right, Mary, there's still many, many idealistic people, people that are searching for meaning in their work. And that really still drives the growth of medical school applications, despite all the challenges. And there's a lot of creative, smart people working on this as well.
Bruce:
And for all of the challenges that we're describing, the burnout, nursing, medicine, pharmacy, the various therapies, they're all still wonderful fields. I think the challenge is to be able to create a work environment that is worthy of the idealism of these young people.