Everyone prays for vaccines, herd immunity, or unforeseen factors to banish the bear. Healthcare professionals are finding ways to tame it.
Everyone prays for vaccines, herd immunity, or unforeseen factors to banish the bear. Healthcare professionals are finding ways to tame it.
Leadership is that part of your job you can’t abdicate or delegate. If you duck, everyone knows. Unless you recover and make amends, you sacrifice your moral authority and your good name. Dr. Stephen Blattner, Founding Principal of exăgoMD, a leadership effectiveness consultancy, told me that the job of leadership “is to evolve a culture of empowerment, to name and address elements of systemic issues that can be impacted at a local level, and to encourage those within their purview to operationalize and measure even small changes that are within their control.” And this applies to self-leadership as well.
The case of the Mayo Clinic interweaves the importance of institutional leadership and self-leadership. Dr. Tait Shanafelt, chief wellness officer at Stanford University, working with Dr. John Noseworthy, Mayo’s CEO, has charted a course for evidence-based improvement in hospital systems, with burnout being of paramount concern. The first of nine strategies they recommend is to demonstrate that the organization cares about the well-being of physicians and to invite candid dialogue—a leadership role as important as any.
The second strategy they outline is to harness the power of leadership and authority. The right leaders must be in place, they must be properly prepared for their roles, and they must be routinely evaluated by the people they lead. With leaders walking the talk, Mayo has accomplished a remarkable outcome: after just two years of focused work, burnout among physicians decreased by 7% while it was increasing by 11% nationally. Burnout has been reduced among non-physicians as well.
The right leaders must be in place, they must be properly prepared for their roles, and they must be routinely evaluated by the people they lead.
Simply put, as Dr. Jennie Byrne, Chief Behavioral Health Officer at CareMore Health told me, “Providers want to be led by professionals who care for them.”
At Mayo, providing resources for resilience and self-care is another essential strategy. Pains are taken to avoid signaling that physicians are the problem, while encouraging them to take better care of themselves. Broad-brush training is not what is meant. Instead, resources are highly specific to individuals and their situations, beginning with self-calibration. When their intrinsic other centeredness goes unchecked, healthcare workers may be the last to know if they are experiencing critical levels of stress.
Wayne Sotile, founder of the Sotile Center for Resilience and Center for Physician Resilience, and author of The Thriving Physician, observes: If 90% of burnout in healthcare is due to institutional malaise, 10% is the personal responsibility of individuals. Self-leadership means taking Dr. Watson’s entreaty to heart: “Make a commitment to endure, using whatever coping skills work for you….”
Dr. Mona Hinrichsen is Chief of Hospital Medicine at North Shore Medical Center in Salem, Massachusetts. She says that that one of her most important responsibilities is to look after her team.
Before the crisis hit in full force, Dr. Hinrichsen had received an email from a primary care physician saying, “If you need me, I’m here.” When the surge of “incredibly sick patients” occurred, the ICU suddenly tripled in size, as doctors, affiliates, consultants, cardiologists, endocrinologists and others rallied to help.
“If you need me, I’m here.”
Dr. Hinrichsen ensured that no one was left out or uncared for. Locum tenens doctors were fully supported and welcomed in daily team meetings. Psychiatry offered support for families of patients with COVID-19 and for providers and their families. The president of the hospital met with the team and committed to address shortages. Meetings began as forums for updates about equipment and PPE, and they rapidly evolved into conversations about the disease and how to care for patients, their families, and each other.
Soon suggestions bubbled up from front-line members about possible changes and improvements. One person suggested having cards at hand with a phone number for translation services—Salem is home to 100 different languages. Lists of resources became standard practices, from simple things such as how to transport a patient, to complex things such as monitoring patient decline. Other ideas came top-down. “Everything learned in our past helped us to tackle each challenge.”
These meetings at North Shore Medical Center seem to fit an emerging pattern in healthcare, according Dr. Blattner. No longer are meetings viewed by staff as interruptions in the delivery of care. Now they are deemed essential, “to congeal teams, plan operational change, and provide mutual support.” And this new awareness of the value of team meetings in order to build teams has not been diminished by the use of virtual meeting technologies. “Meetings have emerged as the mainstay of the COVID-19 response for hospitals and health care organizations around the country,” Dre. Blattner told me.
Dr. Hinrichsen checks in with everyone for whom she feels responsible—40 core staff plus 36 primary care physicians and consultants—by making phone calls, hosting conferences, texting, and more. “I want us to talk about what we’re feeling and doing,” she says. But for her it’s more than reaching out. It’s following up. Dr. Hinrichsen’s team is a study of compassion in action.
Specialists from outside the hospital have volunteered, learned new roles and asked for help when needed. Nurses, at the forefront of care, have ably managed the surge of new patients. Everyone has pitched in. And now everyone looks the same.
Dr. Jessica Benedetto, an internal medicine physician at North Shore, detailed in an essay she titled, “We Are All in This Together,” how teams are collaborating now more than ever. Specialists from outside the hospital have volunteered, learned new roles and asked for help when needed. Nurses, at the forefront of care, have ably managed the surge of new patients. Everyone has pitched in. And now everyone looks the same. Hierarchical signifiers like white coats and stethoscopes have been replaced by scrubs and scrub caps, N95 masks, face shields, gowns, and sneakers.
The hospital is generating extraordinary, positive energy in response to the pandemic. And North Shore’s healthcare teams have discovered a “silver lining” in the crisis: unprecedented collaboration and teamwork.
Therapists around the country have lined up to offer free trauma recovery treatment to medical workers, but, according to The New York Times, the response has been modest. Perhaps physicians fear that if they pause for treatment, they’ll crash. Or they feel that patients or co-workers are more important. Or they feel they will be stigmatized for seeking help. Or they will feel guilty for being selfish and taking a break. Or they think they’re really OK, after all.
People in healthcare jobs are guided by many ideals: selflessness, a moral code, a mission to serve, dedication to a calling, loyalty to their colleagues, high standards for behavior and high expectations to achieve results, courage under fire. Stoicism, choosing not to reveal one’s vulnerability, may be the underlying mentality.
In order to create and sustain an environment where self-care is primus inter pares, the ethos must be one of safety. Providers must feel safe, safe enough to lay their burdens down, even if briefly..
In order to create and sustain an environment where self-care is primus inter pares, the ethos must be one of safety. Providers must feel safe, safe enough to lay their burdens down, even if briefly, without loss, cost, exposure, or sense of failure. Haranguing physicians to “heal thyself” is as counterproductive as forcing them into “training.”
At Johns Hopkins Hospital, all healthcare workers in the system are eligible to seek supportive counseling no matter the cause of their stress, through a program called RISE, Resilience in Stressful Events. Dr. Albert Wu, a professor in the Bloomberg School of Public Health, wrote a paper in 2000 titled, “Medical Error: the second victim,” which became the source document for RISE: a peer-to-peer service for healthcare workers, available 24/7. Two dozen peer responders carry pagers and try to respond within half an hour and to appear on the scene in the same shift.
According to Anna Koerbel, Business Development Manager for RISE, there has been a dramatic shift in the immediacy of need during the COVID-19 crisis. There is an increase in support requests and in interest in the training. Now more than 40 hospitals and healthcare systems have been helped by RISE staff to launch peer support programs of their own.
RISE makes it safe to get help. First, all calls are completely anonymous. There is no record of who called and why, and no one follows up after the fact. Second, call-takers have passed a training program to be volunteer responders, but they all have day jobs in the medical community. Third and equally important, responders are forbidden to be problem-solvers. They are trained to say, “I can’t help you with that (actual problem), but let’s talk about your stress.” The purpose, Koerbel reports, is to “stop the bleeding,” and most of the time it works.
Research in psychotherapy suggests that 85% of why a person gets better is due to two factors: the motivation of the help-seeker, and the ability of the therapist to be warm, caring and compassionate. RISE provides a model that makes it easy for healthcare professionals to seek compassionate care whenever they feel a need.
I spoke with two eminent psychologists in Boston about the nature of their private practice in today’s environment. It was reassuring to hear them say that, beyond sequestering, COVID-19 hasn’t changed what they do. They stick to what works, for them, and they have years of practice as evidence of their success. They encourage people to talk, and they listen.
Duncan Hollomon is a practitioner of mindfulness, and he is also an actor. These two mental modes help him be unafraid of intense emotion, which is a great strength given how he works. His therapeutic techniques are centered around circles, safe settings where people sit together and speak from the heart, without crosstalk. Each person takes a brief turn, without interruption; a talking stick can help impose discipline. The healing comes from listening, being listened to, and learning. The roots of this method, sometimes called the council model, are as old as tribes and may predate pandemics.
Barry Dym is founder and former chief executive officer of the Institute for Nonprofit Management and Leadership, and he is the author of Readiness and Change in Couple Therapy, a seminal text. Given his wide-ranging career, I asked Dym how he worked with traumatized people or any group of adults wanting to learn, grow, or heal. I was most curious to know how he encourages therapy-averse professionals (e.g. physicians) to participate in groups.
He leads Case Learning Seminars, problem-solving groups conducted over a period of time, whereby participants listen to each other’s occupational challenges and lend a hand. Seminars begin by focusing outward on the jobs they do and the situations they find themselves in, as opposed to taking a reflective, psychological approach.
The technique is simple, yet in the hands of a skilled therapist, disclosure and collaboration ensue, empathy grows, and trust builds. One person presents a case, a problem or situation or experience, naming where they want help. Others offer their views or ask questions attempting to be genuinely helpful. The cycle of sharing, listening, offering feedback, thinking about challenges that may be unique to another person while common to all, and then taking responsibility for oneself, is generative and healing. When learning from each other is practiced until it becomes habitual, self-care is the reward.
The Schwartz Center for Compassionate Healthcare was created from an idea by Kenneth B. Schwartz shortly before died of lung cancer in September 1995. In his final days he wrote an article in poignant detail for Boston Globe Magazine that has had a ripple effect around the world, upending embedded and unexamined notions about healthcare.
He courageously recounted his suffering, the treatments he endured, and the progress of his disease. What potentially turns the healthcare zeitgeist on its head is the powerful and eloquent way he expressed gratitude to all those who treated him and ministered to his physical and psychological pain.
He courageously recounted his suffering, the treatments he endured, and the progress of his disease. What potentially turns the healthcare zeitgeist on its head is the powerful and eloquent way he expressed gratitude to all those who treated him and ministered to his physical and psychological pain. He recounted “moments of exquisite compassion” and acts of human kindness that made the “unbearable bearable.”
Schwartz, who was a healthcare lawyer, wondered if he had received special care due to his privileged connections in medicine. The Schwartz Center puts compassion at the heart of healthcare for anyone seeking it.
The signature program is Schwartz Rounds. Rounds are usually monthly, one-hour town hall-type meetings, highly structured, where physicians, nurses, social workers and medical specialists are encouraged to share their stories, insights and feelings. The topic may be a subject, like burnout, or a case where the patient is held anonymous. The unique dimension of Schwartz Rounds is that people attend on equal footing—there is no hierarchy of status or expertise. The premise is that making personal connections
with others, in a multi-disciplinary and safe environment, builds personal insight into one’s reactions and responses.
According to the evidence, participants experienced greater appreciation of their colleagues and improved teamwork; decreased stress and feelings of isolation; and increased readiness to respond to the needs of patients and their families. In 2015, 85% of staff who attended Schwarz Rounds reported that they were now able to provide more compassionate care.
Dr. Goldberg reports that there are now 550 member hospitals hosting Schwartz Rounds. Now that social distancing and virtual meeting technologies have become ubiquitous, as many as 900 people were able to attend in one recent Round, and 300 in another. “People are desperate for it.”
In 2012, a prescient article appeared in the Journal of the Royal Society of Medicine, contending that “the true heroes of our hospitals are not the nurses or the doctors but the patients.” Most patients are not necessarily courageous people before they are afflicted. Yet through the compassion of their caretakers, when fighting for their lives, they can become gutsy, gritty and even heroic. When caretakers take care of themselves, they take better care of their patients. Self-compassion entwines with compassion in life’s most critical, most ennobling moments.
This article is second in a series that tells the story of how physicians can develop coping skills to manage extreme burnout. Read the first part here