Published in the May 2014 issue of Today’s Hospitalist
IF IT WERE UP TO HIM, hospitalist Abeezar Shipchandler, MD, would be able to duck out to an adjacent gym when his daily schedule permits. That way, he and his colleagues on the medical staff at Baylor Regional Medical Center in Plano, Texas, wouldn’t have any excuse for not staying fit.
Sowmya Kanikkannan, MD, hospitalist medical director for the Rowan University School of Osteopathic Medicine program at Lourdes Medical Center in Willingboro, N.J., would also like onsite exercise programs, including “accessible” options such as 30-minute Pilates classes every day at noon. “I would also build in true breaks during the workday,” Dr. Kanikkannan says, “to help hospitalists center themselves.”
Another wish-list item: Michael Janjigian, MD, director of inpatient general medicine at Bellevue Hospital in New York City, would substantially cut hospitalists’ daily census on the busiest rotations.
“I would decrease patient loads to a target census of about 14,” says Dr. Janjigian. “I would also make changes to give our hospitalists a way to call in sick if they need to, without feeling guilty.”
Here’s the question these physicians were posed: If you could make system-level changes to help hospitalists improve their personal wellbeing and avoid burnout, what would those be?
The numbers on physician burnout aren’t reassuring. In one 2012 study published in the Archives of Internal Medicine, Mayo Clinic researchers found that 38% of 7,000 U.S. physicians surveyed (across all specialties) reported emotional exhaustion, while 46% reported some burnout symptoms.
According to the 2013 Today’s Hospitalist Compensation & Career Survey, more than two-thirds (68%) of responding hospitalists admitted that burnout was either significant or very significant for them personally. Their outlook on the specialty was even worse: A whopping 87% reported that burnout was significant or very significant within hospital medicine.
Unfortunately, few system-based resources have been devoted to taking care of those who take care of patients. But recent research has started to remove the stigma of doctors admitting that they may need help, and hospitals and health systems are beginning to see that a burned-out workforce can’t provide high-quality care. Things are shifting “if slowly.
Organizations are launching employee wellness programs, or at least considering them. Hospitalist programs are devoting more resources to holding down the census to help mitigate burnout.
Some institutions are organizing small-group discussions so doctors can explore the outsized stresses of their job together. And physicians themselves are losing some of their “boot camp” mentality to focus on what they can do to help themselves.
At Swedish Medical Center in Seattle, physicians have access to classes in relaxation techniques and mindfulness-based stress reduction (a combination of meditation and yoga), and even 20-minute neck and shoulder massage sessions.
“There is a growing realization that physicians are human beings too, that they need to care for their own health and that they might need some support in that,” says veteran Swedish hospitalist Sandeep Sachdeva, MD. “I hope we’ll start seeing more of this nationwide.”
Dr. Sachdeva also sees more doctors taking steps to safeguard their own wellbeing. Take his hybrid hospitalist-palliative care practice, for instance. He moved to his current schedule after a few years as a nocturnist, in part to avoid jeopardizing his health.
“Hospitalists who went into this field 15 years ago are becoming more aware as we move into mid-career that we have to take care of ourselves,” says Dr. Sachdeva, who finished residency in 1996.
But taking care of yourself can be hard to do, given the inherent stresses of the job. Most practices are fast-paced and perennially understaffed.
And typical schedules, seven-on/seven-off in particular, pile on the stress, observes Julia Wright, MD, a longtime hospitalist who is chief medical officer at Beaver Dam Community Hospital in Madison, Wis.
“A 12-hour shift is really a 14-hour shift, plus some driving “and that’s 100% work for that period of time,” says Dr. Wright, who previously worked in management for Cogent Healthcare and once headed the hospital medicine program at the University of Wisconsin Hospital. “Then you sleep and go back again, which is very demanding physically and emotionally.”
Franklin Michota Jr., MD, director of academic affairs in Cleveland Clinic’s hospital medicine department, cites other pitfalls that go with the turf: working weekends and nights.
“I think that creates irritability and resentment that will subconsciously affect levels of empathy,” Dr. Michota says. “Many hospitalists recognize the need to decompress and the importance of free time for oneself and family. But when you are on the schedule, you are there so that someone else can be off “and it’s not like there are hospitalists waiting in the wings to take over when you are stressed.”
Dr. Wright also points to the “scope creep” in hospital medicine and to ever-growing amounts of paperwork and documentation. And she notes hospitalists’ increasing responsibilities for quality improvement, patient communication and citizenship activities that can’t always be squeezed into an already long day.
“It used to be that when you’re off, you’re off,” Dr. Wright points out. “But now, hospitalists are being asked to do more nonclinical work during what used to be considered off time.”
According to Dr. Shipchandler, his physician practice group, Health Texas Provider Network, offers many nonclinical opportunities “in administration, committee work, quality improvement or teaching ” to doctors who wish to pursue them.
But those come at the cost of being done in “off time.” For hospitalists coming out of residency, he notes, the challenge is trying to budget the time to make the most of their careers while taking care of themselves and not stretching themselves too thin.
Another big challenge for doctors right out of training: adjusting to the new era of health care. While residencies primarily focus on patient interactions and clinical decision-making, hospitalist programs now additionally stress quality metrics, EMR usage and the business of medicine.
“A frequent frustration I hear from our new physicians is this: They feel the most important part of their job, which is time with the patient, is being sacrificed as they juggle all these other responsibilities,” Dr. Shipchandler says. “Their own wellbeing and making time for themselves is caught in between.”
Then there are factors related to working in such a young field, says Dr. Kanikkannan. That includes a lack of awareness among specialists of what hospitalists do. Despite the specialty’s track record, medical staff often under- or overestimate hospitalists’ scope, she says, which brings its own level of stress.
There’s also this problem that particularly affects smaller programs: the lack of robust business support. Other specialties, Dr. Kanikkannan points out, tend to have established administrative and billing services. But that may not be the case for smaller hospitalist programs, which leaves the hospitalists essentially doing their own billing.
“They have to build that into their day when they’re already so busy,” says Dr. Kanikkannan. “Because it’s such a young field, we just don’t have good systems in place. It feels as if we are always scrambling to keep up.”
In terms of an alternative to traditional schedules, “We need to come up with ways to make schedules more livable, to enable hospitalists to spend more time at home and actually have dinner with their families,” says David Frenz, MD, a hospitalist and addiction medicine specialist at HealthEast Care System in St. Paul, Minn.
“Small tweaks probably aren’t enough. As a field, we might have to fundamentally retool and move to multiple short shifts per day, limiting duty to five days a week.”
While few institutions right now are making that kind of investment, more hospitals are creating wellness programs for employees. At HealthEast, for instance, where Dr. Frenz is medical director for the system’s Ways to Wellness program, several initiatives are underway.
HealthEast’s cafes and vending machines are being revamped to serve healthier food, for instance. The system is also considering “healing spaces,” quiet rooms where employees can take a time-out. “Hospitals are busy, over-stimulating places, and not even the doctors’ lounge provides any refuge,” Dr. Frenz says. “The hope is that, eventually, we will have a lot of places throughout our organization where employees can recharge.”
Also being considered: exercise options for hospital staff. While patients who’ve had knee replacements can already exercise on campus, he points out, “there’s no place for providers to do that.”
Baylor Scott & White Health, the system that Dr. Shipchandler works in, has likewise instituted an employee wellness program called Thrive. It focuses on preventive health, nutrition, exercise, and physical, social, and spiritual wellbeing, with offerings that target stress reduction.
“Given their complex schedules, the challenge for providers is being able to use these resources,” Dr. Shipchandler says. “Having a routine would be ideal, but ‘routine’ is not something that really exists in our field any more.”
And while such programs speak to a hospital’s commitment to bolster wellbeing, physicians experiencing stress or burnout may need more intensive resources.
“Healthier diet options in the cafeteria are wonderful, and they’re good for overall health and wellness,” says Colin West, MD, PhD, a general internist at Mayo Clinic who co-authored the 2012 Archives study as well as a study published in JAMA Internal Medicine last month on physician wellbeing. “But such options probably aren’t a fix for burnout.”
To stave off burnout and make work life more manageable, hospitalist programs are also changing practice parameters. At Bellevue, for instance, Dr. Janjigian says the program has eliminated call duties for the hospitalists on rotation in the highest-volume service (20 patients). The program has also revised the schedule so that no hospitalist stays on that service more than two weeks in a row.
Dr. Janjigian has also devised a system to distribute admissions more evenly “to ensure fewer boluses,” he says. “We want to avoid having teams receive large numbers of admissions one day and none the next.”
Cleveland Clinic has created what Christopher Whinney, MD, director of the hospital medicine fellowship program, calls “a very robust jeopardy system.” Additional providers are called in when volumes spike beyond what most consider “safe”: the 15to 20-patient range.
“We err toward the lower number at our main campus due to patients’ higher acuity and complexity,” says Dr. Whinney. “This is a tremendous resource when providers know that the department has their back.” The same jeopardy system is being tested at the system’s other four hospitals.
According to Dr. Michota, the continued tweaking of the hospitalist schedule has helped deter burnout. “We generally limit in-service work to two weeks in a row, we average 12 weekends or less a year, and we’ve minimized the number of night shifts by setting up the nocturnist program,” he says. Mixing outpatient preop consults into the schedule has also helped, he says.
In New Jersey, Dr. Kanikkannan’s program allows flexible use of vacation days. She encourages hospitalists to use Rowan University’s counseling services for burnout prevention. And when hospitalists hit a tough spot, she has them take a “breather” for a short while and re-center while the rest of the team pitches in.
“People shouldn’t be so depleted by their work that they can’t do anything else when they get home,” she says.
As for promoting wellness at North Hawaii Community Hospital in Waimea, “it doesn’t hurt to live in Hawaii,” says Jennifer Real, MD, medical director of the hospitalist program. But her group has abandoned the “you stay until you’ve seen all your patients” mentality, she says. Now, hospitalists are encouraged to hand off patients when their shift ends.
“That has helped ensure more reliable work hours,” Dr. Real says.
A menu of options
For Mayo Clinic’s Dr. West, who studies physician wellbeing, the key is offering a menu of options to address a broad range of symptoms.
“It’s a bigger problem than any one intervention can address,” he says. “You need multiple tools that physicians and institutions can draw on and as big of a toolkit as possible.” His most recent study looked at the effectiveness of small-group discussions among physicians, focused on meaning in work, personal and professional balance, and medical community.
“If having yoga at 6:30 in the morning works for some people, then make it available,” Dr. West points out. “Same with engaging in small groups or building more flexibility into schedules.”
The next step for hospitals, he adds, is to take a page from the business world (think of all those employee perks that Google offers) and fully recognize that “the investment in a satisfied workforce pays major dividends down the line. But sending physicians to a stress management workshop for an hour as your hospital’s institutional contribution isn’t going to do it. Each specialty in each institution has to figure out the right menu of options for them.”
Bonnie Darves is a freelance health care writer based in Seattle.
HOSPITALISTS WHO RECOGNIZE THAT WELLBEING is primarily up to them make time for what’s important, no matter what. Sources for this article shared their personal strategies:
- David Frenz, MD, HealthEast Care System, St. Paul, Minn.: “I’m a vegetarian. I work out consistently “we’ve got an elliptical in the house “even when the kids are in the living room. I also make sure that I sleep seven hours.”
- Franklin Michota Jr., MD, Cleveland Clinic: “I am learning to say ‘no’ to extracurriculars at home and at work, and I am OCD about my calendar and planning ahead. Exercise and time with family are high priorities.”
- Jennifer Real, MD, North Hawaii Community Hospital, Waimea: “I am learning how to surf, and two of the other hospitalists surf as well. In Hawaii, people tend to be focused on work-life balance, and that’s one reason I came here.”
- Sandeep Sachdeva, MD, Swedish Medical Center, Seattle: “I am very focused on exercising and have been for several years. I hike, and I recently started doing CrossFit. I also try to eat well, but that’s a struggle.”
- Julia Wright, MD, Beaver Dam Community Hospital, Madison, Wis.: “I invest in great friendships, I exercise and I am careful about nutrition. I am blessed to have a wonderful family, and we spend a lot of time together. I also am involved in my church “I find that focusing on helping others is rejuvenating.”
Calling Code Lavender
TWO ORGANIZATIONS – the North Hawaii Community Hospital in Waimea and Cleveland Clinic – have implemented a program that encourages caregivers to signal an alarm when the going gets too tough.
Physicians, nurses and other clinicians have access to the intervention in the wake of a patient death, an onsite crisis, or an especially challenging patient or family encounter. Called “Code Lavender,” the service is a rapid response program that incorporates healing touch and massage, spiritual support, and other elements as needed. It’s also available to patients, but in both facilities, most “codes” have been called by or for providers.
“I am not aware that hospitalists have used Code Lavender, but it’s nice to have it available “and if a staff member calls for one overhead, many people show up to offer support,” says Jennifer Real, MD, medical director of the hospitalist program at the Waimea hospital. Arielle Michael, director of North Hawaii’s holistic services, notes that even if relatively few physicians have accessed the service themselves, they strongly support the program.
“They see the benefit of it,” Ms. Michaels says. “They realize that we have to nurture the caregivers, too, and physicians are good about calling a code” when colleagues are in a bad way.
At Cleveland Clinic, 128 Code Lavenders have been called for physicians, nurses or other clinicians since 2011. Franklin Michota Jr., MD, the director of academic affairs in the hospital medicine department, suspects that the hospitalists are generally unaware of Code Lavender as an option for themselves and unlikely to call one for that purpose. That’s not to say, he notes, that high-stress situations are rare.
“Physicians need to ensure that patients get good care, and certainly that means a level of attention to the stress of the care team,” Dr. Michota explains. “I can see a physician calling a Code Lavender for a stressed nurse, for example, but I don’t see doctors having that much insight as to their emotions or self-awareness.”
Mindfulness: a tool to help manage stress
HOSPITALISTS WHO WAIT for their groups or hospitals to promote stress-reduction techniques might wait a long time. Carl Fulwiler, MD, PhD, an associate professor of psychiatry and director of the System and Psychosocial Advances Research Center at the University of Massachusetts Medical School in Worcester, advises hospitalists to instead take steps to better cope with work factors they cannot control.
One technique he recommends is mindfulness-based stress reduction, a practice that combines meditation and yoga to focus awareness on the present moment.
Dr. Fulwiler, who treats hospitalists suffering from burnout, acknowledges that learning how to tune out the noise and be in the present is challenging. But it’s also not as time-consuming as some physicians think. “It’s not about how long you sit, it’s about the attitude you bring “to be fully here, with your internal experience,” he says. “The challenge for us is to present mindfulness in a way that’s not overwhelming.”
Formal mindfulness-based stress reduction programs, which were first launched at UMass, are growing in popularity and are now offered in more than 500 U.S. health care facilities. Dr. Fulwiler also recommends that hospitalists form wellness groups with other physicians to talk about how mindfulness can help them in their work.
“Support is important,” says Dr. Fulwiler. “Trying to do this on your own is difficult.”