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Bend, but don’t break

Boosting resilience is one strategy for mitigating burnout

June 2017

REGULAR READERS know that I’ve been fixated on both money and provider burnout. And with good reason: The two form a vicious cycle. Pressure to produce—either by your hospital or self-imposed—often leads to burnout. Burnout, in turn, reduces patient satisfaction, prolongs patient recovery time, contributes to medical errors  and leads to provider turnover. These nasties cost your employer money, which further intensifies the pressure to produce. And so the wheel of misfortune turns.

Breaking the burnout cycle requires both organizational and individual strategies. I explored the former in my October 2016 column (“Beating burnout“). This month, I’m going to start tackling the latter.

Job-person mismatch
Psychologists Michael Leiter, PhD, and Christina Maslach, PhD, literally wrote the book on burnout. In their “Banishing Burnout,” which was published in 2005, they define burnout as a syndrome involving a “poor fit and major mismatch” between you and your job, characterized by unhappiness, exhaustion and cynicism.

Systems are fantastically hard to change. You can often produce bigger change faster at the individual level.

Hospitalists immediately think of duty hours, encounters per shift and RVUs. While workload is generally part of the problem, Drs. Leiter and Maslach have identified five additional factors that affect burnout: control, reward, community, fairness and values. For more on this, please see my April 2016 column (“How’s your relationship with work?”).

When burned out, your first impulse is to demand that your employer fix the problem: reduce your workload, give you more autonomy, boost your compensation and so on. And most health care executives would love to oblige. But things are much more complicated than they appear. Hospitals are dysfunctionally homeostatic: Improving workload will undoubtedly mess up other stuff and could make your life worse, not better.

After working on the job side of this equation for years, I’ve concluded that it’s generally more productive to take the person angle. Systems are fantastically hard to change, and you can often produce bigger change faster at the individual level.

Bouncing back
The American Psychological Association defines resilience this way: “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress—such as family and relationship problems, serious health problems or workplace and financial stressors. It means ‘bouncing back’ from difficult experiences.”

But what makes someone resilient? Gail Wagnild, PhD, who has devoted her career to the subject, has developed a five-factor model. Here are the elements she identifies:

  • purpose
  • self-reliance
  • authenticity
  • perseverance
  • equanimity

Each of these factors has a specific meaning. For example, Dr. Wagnild defines purpose as “having a sense of meaning in your life and a reason to get up in the morning.” Likewise, equanimity denotes “living with balance and harmony and choosing your response to life’s ups and downs.” Taken together, optimizing these five elements is a recipe for both surviving and ultimately thriving.

Measure to manage
I’m a scales-and-measures junkie. It’s hard to manage something that you can’t measure. When working with clients, I generally start by administering the Maslach Burnout Inventory (MBI) and the Areas of Worklife Survey (AWS). The former is the gold standard for measuring burnout, while the latter assesses job-person fit.

The next step is to assess resilience. While there are many options, the Connor-Davidson Resilience Scale (CD-RISC ) and True Resilience Scale (TRS) get high marks from psychologists. Both instruments consist of 25 Likert-type items. Here are, for example, two items from the CD-RISC:

  • Having to cope with stress can make me stronger
  • Even when things look hopeless, I don’t give up

Like all good psychological instruments, both scales give you a sense for where you stand compared to external benchmarks. As demonstrated in the chart (see “How I measure up” below), I’m merely average.

coding chart

The TRS also provides subscale scores for Dr. Wagnild’s five components of resilience. I scored 87 (out of 100) for both purpose and self-reliance, which places me in the “flourishing” range. (“Thriving,” the highest range, requires a score of 90 or better.) I scored lowest on the equanimity subscale, where my 70 fell into the lower end of the middling “growing” range, which is just a few ticks above “developing.”

Physician, heal thyself
I’ve had doctors as both patients and employees. To a person, they’re smart and capable but not particularly self-aware. Psychological instruments raise consciousness and point toward potential solutions. (Imagine rounding on your patients without the benefit of vital signs, lab data and imaging results. Scales and measures are basically the psychological equivalent.)

So let’s say you complete the MBI, AWS and TRS, and your numbers suck. Now what? Alas, I’ve hit my word limit for this month and will need to leave you in suspense. But I promise to return—likely in August— with some prescriptions for improving your resilience. Just e-mail me in the meantime if you’re completely desperate: email@doctorfrenz.com.

New coding-frenzDavid A. Frenz, MD, just put his career on pause. He was most recently vice president and executive medical director for North Memorial Health in Robbinsdale, Minn. You can learn more about him and his work at www.davidfrenz.com or LinkedIn.



Published in the June 2017 issue of Today’s Hospitalist
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