Helping Healers graphicUAB Medicine is stepping forward to address physician burnout and promote wellness among faculty and staff.

Much has been written about the ongoing upheaval in the health care system. From passage of the Affordable Care Act to changes in reimbursement rates to implementation of electronic medical records (EMRs), wave after wave of innovation and disruption have brought sometimes painful changes to the medical profession.

The entire health care industry is becoming increasingly complex. The workload grows, while the number of hours in the day remains the same, constricting time for vital physician-patient interaction. Insurance and payment methods vary greatly from person to person, further complicating the system. Office work regularly carries over to home life, and the pressure of the daily grind follows right along with it.

In the midst of this transformation and turmoil, a worrisome trend has become more noticeable. Surveys indicate that burnout and depression have increased substantially within the medical community in recent years. Commonly recognized symptoms of burnout include emotional exhaustion, in which a physician feels drained after the work day and is unable to recover with time off; depersonalization, which typically presents as cynicism or an excessively detached response to patients (also known as “compassion fatigue”); and a loss of a sense of personal accomplishment.

Researchers at the Stanford University School of Medicine found that 54.3 percent of physicians in active practice reported symptoms of burnout, 32.8 percent reported excessive fatigue, and 6.5 percent had even considered suicide. In severe cases, this is a problem that affects patients as well as physicians. Approximately 10 percent of physicians reported making a major medical error in the three months before the survey, with half those errors being fatal.

“We’re not in a full-blown crisis yet, but we have a problem that needs to be attended to,” says David Rogers, M.D., MHPE, who was named to the new position of UAB Medicine’s chief wellness officer in January. “We have to go in a different direction if we expect people to continue to have great experiences in this profession. We have to get this sorted out for the next generation, or it’s going to continue to escalate.”

Rogers, a pediatric surgeon, speaks from personal experience. He says there have been times when he was so exhausted from working long stretches that he could not perform simple math while doing the calculations for parenteral nutrition in a child. Eventually, his colleagues noticed that his weariness was sapping his passion for the job.

“A good friend came to me who said, ‘You’re not well. You’re not impaired, but we don’t see the enthusiasm in you that we’ve seen in the past. You’re not excited about the things that have always excited you before,’” Rogers recalls. “Part of burnout is becoming emotionally exhausted. You just don’t have the energy, and you feel like that’s your fault somehow so you withdraw.”

UAB is addressing the myriad challenges to physician wellness thanks in part to the ProAssurance Endowed Chair for Physician Wellness, the first academic chair of its kind in the U.S. Established with a $1.5 million gift from Birmingham-based ProAssurance Corporation, the chair is tasked with researching physician wellness and developing programs to promote a sustainable culture of wellness and provide both faculty and staff with tools and resources to manage stress and avoid burnout.

Understanding the Problem

FrazierRogersVersion2David Rogers (right) is UAB Medicine’s first chief wellness officer and the inaugural holder of the ProAssurance Endowed Chair for Physician Wellness in the School of Medicine. Sandra Frazier (left) is medical director and assistant dean of professional development. Photo by Nik Layman.While long hours, lack of personal time, and stressful scenarios are nothing new in the health care field, recent changes in the profession seemingly have made matters more difficult. Rogers says one of the leading factors is the introduction of electronic medical records, which has added a new layer of time-consuming responsibility.

“On a national level, physicians didn’t realize how burdensome these systems were going to be,” Rogers says. “They can see the value of the EMR and the long-term benefit, but right now it feels like a hindrance. They are dealing with the EMR at night and on weekends. Nurse practitioners are often heavily in the system after hours, too, which speaks to this tool being more problematic than it was promised to be.

“In addition, we are in a period where health care is being radically reformed and some would say disrupted. So you’re seeing the coalescing of health groups into large-scale systems, and physicians feel like we’re giving up a lot of autonomy. There is a sense that you’re just a widget and not performing the traditional role of a physician.”

One of the initial ways Rogers hopes to address burnout is through the use of the Well-Being Index, a nine-question survey created by the Mayo Clinic to measure a person’s level of stress and depression.

“This tool gives you immediate feedback regarding where you are in your well-being compared to your national peers,” Rogers says. “That’s important, because physicians are really poor at self-care. We are the world’s worst patients. This program gives you anonymous, confidential information. And it allows you to track your score over time, so you can see if there is a negative trend developing.”

The new Endowed Chair for Physician Wellness is only the latest example of UAB’s commitment to improving conditions for our faculty and trainees. Sandra Frazier, M.D., has been overseeing the School of Medicine’s Professional Development Office for 12 years. She provides free and confidential coaching, counseling, and consultation for health care professionals—M.D./D.O. and Ph.D. faculty, fellows, residents, and medical students.

“I started the office because I know that our patients only receive the best care when we as providers are paying attention to our own well-being. In other words, I want to provide care for caregivers—those on the front line taking care of patients. We need to foster a culture where it’s not only OK to ask for help but also encouraged. As a primary care physician, I understand the rigors and challenges of medical school, residency, and being a faculty member. This office is my way of giving back to my profession.”

Working Together

VineetaKumarVineeta Kumar is the lead facilitator of the Schwartz Rounds at UAB. Photo by Andrea Mabry.Frazier says some of the biggest contributors to burnout are the increase in the overall workload, reduced autonomy, and complex systemic issues. She says the key moving forward is for the entire medical community to adopt a more unified approach to providing care.

“One answer to burnout is team-based care,” Frazier says. “It is neither best for us nor our patients to function in siloes. Every member of the health care team should take ownership of our patients and work effectively and collaboratively as a team to provide the best care. When we do this, I think we will all enjoy what we do more and look forward to coming to work.”

Since 2009, UAB has also worked to support physician wellness by taking part in the national Schwartz Rounds program, which offers health care providers a monthly meeting where they can openly discuss the social and emotional challenges they encounter. “This is a program that allows dialogue,” says Vineeta Kumar, M.D., professor of medicine and the lead facilitator of Schwartz Rounds at UAB. “We talk about the nonclinical aspects of care and the emotional content of medicine. It’s a place where people are willing to share their vulnerabilities and question themselves. It’s a dialogue that doesn’t happen anywhere else in the hospital.

“It reduces stress and feelings of isolation, and lets you know that you’re not the only person going through this,” she continues. “It also provides an understanding and appreciation of each other’s roles. It’s really gratifying for junior physicians when they hear senior physicians talk about these things and realize it’s OK to show the heart behind what we do. We have ups and downs, but working together as a team strengthens us.”

Supporting Trainees

ResidencyProgramUAB’s residency programs are tackling the issues around physician wellness in individual and creative ways. Photo by Andrea Mabry.Feeling overwhelmed and stressed out has long been considered merely part of the process of learning to become a physician, but UAB is working to change this dynamic by extending its wellness efforts to encompass residents and medical students.

“It’s easy at times to get really focused on meeting goals and having a lot of accomplishments, so something like wellness tends to fall by the wayside,” says Anand Patel, M.D., co-chief resident in the Department of Radiology. “Wellness is not focused on as much, because it’s not something you can set as a concrete goal. Besides, when you’re young, you don’t think you have to take care of yourself that much.”

Many residents discover the hard way that ignoring feelings of burnout does not make them go away. UAB is addressing the problem with a variety of resident wellness programs and initiatives, which includes working with Frazier and the Office of Professional Development to provide confidential coaching, counseling, and consultation. Some measures are simple, such as giving residents periodic half-days off in order to take care of personal tasks. Other initiatives involve residents getting together for activities away from the hospital.

“We’ve introduced a component of social connectedness,” says Jason Morris, M.D., assistant program director for UAB’s Tinsley Harrison Internal Medicine Residency Program. “We have our residents seek out nonmedical community projects, because the medical tends to become routine to them and they forget the impact they’re having on people.

“This helps reinforce the concept that they’re doing something positive for the greater community as a whole. The idea is if you take a step back and remind yourself of the impact you can have, then it’s easier to stay engaged with a positive outlook on the work that you do.”

Jessica Zarzour, M.D., program director for the Diagnostic Radiology Residency Program, organized a resident retreat this year that included a visit to an escape room, where the residents were divided into teams and had to solve a series of puzzles and riddles, followed by lunch.

“We want to make this an annual retreat that focuses on camaraderie, team-building, and work-life balance,” Zarzour says. “This can address the emotional exhaustion and depersonalization aspect of burnout, with the hope that we’re going to build trust and friendship among the residents and build this group of people who can care for each other.”

UAB is also trying to make the actual work experience more enjoyable for residents. This includes having healthy food readily available, so residents aren’t just eating snacks or grabbing fast food takeout during their long hours, as well as creating relaxation areas where residents can hang out with family members while on call.

“To the credit of our medical school, there has been a huge effort to ensure that physicians remain in touch with the reason they chose medicine as a career in the first place,” says Associate Designated Institutional Official for the Clinical Learning Environment Brenessa Lindeman, M.D. “Because not only do these issues affect the health of our workforce, but ultimately they affect the health of our patients and our ability to care for them.”

006SOM WellnessNick Van Wagoner, associate dean for students, and Caroline Harada, assistant dean for community engaged scholarship, are implementing programs designed to help medical students cope with the stress of medical school and build resiliency and wellness strategies that will last throughout their careers. Photo by Nik Layman.Medical students have their own special pressures to contend with, according to Nick Van Wagoner, M.D., associate dean for students. He says the number of applicants for residency is increasing faster than the number of available positions, and the rate of change in medicine is so rapid that students are required to learn much more today than they did 10 or 15 years ago.

In addition to collaborating with Frazier and the Office of Professional Development to help trainees in distress, the Medical Student Services team aims to help reduce stress through the School of Medicine’s Learning Communities. Each student is assigned to a group of 60-80 students from all four years of medical school, along with a faculty mentor. The Learning Communities meet regularly to discuss a variety of topics, including stress management and wellness, and also have periodic social gatherings.

“We’re working toward a supportive culture, where all our students understand that they are needed and that their success is not contingent on another person’s failure,” Van Wagoner says. “That’s what happens in Learning Communities.”

Third- and fourth-year medical students can also take part in Cases and Conversations, a monthly discussion group that allows them to talk about difficult situations they may encounter, such as the death of a patient or conflicts among members of the patient care team.

“We get together for dinner, and then the students just talk about their experiences from the past month,” says Caroline Harada, M.D., assistant dean for community engaged scholarship. “It normalizes a lot of the emotional responses they have. It also lets them see the levity in some of the situations that they experienced, which can also be very healing.”

The goal of these programs is to ensure that physicians and all members of the health care community are as healthy and happy as they want their patients to be. “This is a cultural change that we need to begin,” Rogers says. “It’s a conversation that will take years to evolve, but we have to be more sophisticated about what we ask people in our profession to do. We need to extend the idea of care to ourselves and our colleagues.”

By Cary Estes
Illustration by Kristin Farmer