broken doctors broken systems transcript · 2018-05-15 · broken doctors, broken systems:...

BrokenDoctors,BrokenSystems:ClinicianMentalHealthinContext

EricLeviFRACS.OtolaryngologistHead&NeckSurgeon.ModifiedfromaPlenaryTalkatCombinedAnnualScientificCongressoftheRoyalAustralasianCollegeofSurgeonsandAustralianandNewZealandCollegeofAnaesthetists.Sydney,May2018.@DrEricLevi

Howdoyoudeliverthebestcareforyourpatient?Moreimportantly,howdoyoudeliverthebestcareforyourpatientinthecontextofinstitutionalandindividualchallenges?Theproblemofclinicianburnoutandmentalhealthiswellknown.Asindividualsandinstitutions,wehavebeengrapplingwiththisissueforsometime.Wehavehadmanyinterventionswithvariablesuccesses.Arewethinkingcorrectlyaroundthis?

Iwouldliketochangeyourmindonthismatter.Ihavenodisclosures.Idohaveadisclaimer.Iamnotapsychiatristoramentalhealthprofessional.Iamasurgeononthecoalface.I

havebeenhitbyfriendlyfireandcoveredinmud.Iwouldsincerelyliketosharemythoughtsasafront-lineworkerandofferthreepossiblepracticalactionplansthatarenotnecessarilyexpensiveorextensivetotacklethisissue.

Doctorwellbeinganddoctorsuicidesareuncomfortabletopicsformanyofus.Wearetrainedtodiagnose,treat,gas,tube,stabilise,fixpatients.UnlikeourcolleagueswhoareGPsandPsychiatrists,weareuncomfortablewiththis“wishy-washy,touchy-feely”stuff.Weknowitisimportantsomehowbutwedon’tknowhowtoapproachit.Wearenottrainedtohelpourcolleagues.Wedon’tknowhowtorespondtoastrugglingcolleague.Thereisacertainawkwardnesswhenweseeourcolleaguesstruggle.

Weknowthatthereisanelephantintheroombutwedon’treallyknowwhattodowiththatelephant.Thedataisclearandhasbeencoveredinmanyotherplaces.Doctorsarestruggling,andtheyarestrugglingquietly.(NationalMentalHealthSurveyofDoctorsandMedicalStudents.October2013.BeyondBlue.)ThesearethenumbersweknowinAustralianDoctorsin2013basedonBeyondBluesurveyofover12,000doctors:1in5hasbeendiagnosedwithorreceivedtreatmentfordepression.1in4hashadsuicidalthoughts.And1in50hasattemptedsuicide.Theriskwithuslookingatthesestatisticsisourcognitive

dissociationfromthisstatisticthesamewaywelookatotherstatisticsandsay“thosenumbersareforthepatients,notforme.”No,thisisourstatistic.Thisisusinthisroom.Thisisthestateofourhealthcarecommunity.InatypicalSurgicalorAnaestheticDepartment,therewillbesomeonewhohashadthoughtsofsuicideandperhapssomeonewhohasattemptedsuicide.Femalesareathigherrisk,andthespecialtyhotspotsforsuicideareGP,EDandanaesthesia.However,it’snotagenderissuebecausemalescommitsuicide.It’snotanageissue,becauseconsultantscommitsuicides,notjusttrainees.Iammindfulthattheremaybesomeofusstrugglingwiththesethoughtsthisweek,orevenrightnow.Ifthatisyou,pleasehearme.Youreallymatter.Youreallydomattertoyourcommunity,tous,andtoourpatients.Pleaseshareyourburdenwithatrustedcolleague,aGPoraprofessionalmentalhealthworker.Helpushelpyoutobeabetterdoctorforyourpatient.

Inviewofthiselephantintheroom,self-careandmanagingmentalhealthisindispensable.It’ssoimportantthatforthefirsttimelastyear,theWorldMedicalAssociationhasincludedself-careaspartoftheirPhysician’sPledgeontheDeclarationofGeneva.ThePhysician’sPledgeisthemodernversionoftheHippocraticOath.In2017itbeginswith:“ASAMEMBEROFTHEMEDICALPROFESSION,ISOLEMNLY

PLEDGEtodedicatemylifetotheserviceofhumanity”.Andthenfurtherdownthepledgeitsays:“IWILLATTENDTOmyownhealth,well-being,andabilitiesinordertoprovidecareofthehigheststandard”.

Icannotstressenoughtheimportanceofmentalhealthandself-careinourcaringprofession.Thisiswhyresiliencetraining,personalcoaching,havingaGPoraprofessionalmentalhealthworkerareimportantandhavebeenshowntoimprovethewaywedealwithworkplacestresses.Ifyousufferfrommentalillness,gettinggoodtreatmentiscriticaltoyourdeliveringcareofthehigheststandardsforourpatients.

ThebigquestionIwouldliketoposeisthis:Isthatenough?Isresiliencetraining,mindfulness&coachingthesolutiontoourproblems?Forthatparticularelephant,yes.

MayIchangeyourmind?I’dliketosuggestthattheremaybeanotherelephantintheroom?Ifwecallthefirstelephantmentalhealth,canIcallthesecondoneInstitutionalHealth?

IamsureyouknowwhatImeanbyinstitutionalHealth:Workplaceconditions,relationaltoxicity,administrativeintrusions,timepressures,excessiveworkload,resourcelimitations,competitionforjobs,poorjobsatisfaction,poorjobengagement,bullying,harassment,sexism,jobmaldistribution,etc.

Burnout.ThisisAustraliandataagainfromthesameBeyondBlueSurvey.Burnoutisdefinedasapsychologicalstatecharacterisedbyemotionalexhaustion,lowjobefficacyandhighcynicismordepersonalisation,duetochronicoccupationalstressinthecaringprofession.ItisnotaDSM5orICD10mentalillnessdiagnosis.Itisapsychologicalstateduetoworkplacestress.Workplacefactorshavestrongassociationwithburnout.Halfofusareemotionallyexhausted,1in6-7noteffective,andhalf

ofusarehighlycynical.Burned-outdoctorsarebadforpatients,andbadforbusiness.They’reineffective.Theymayordermoreunnecessarytests,takelongertocompletetasks,makemistakes,anddonotdeliverhighstandardsofcare.Howcanyoucareforapatientwhenyouareemotionallyexhaustedandcynical?

Whatistherelationshipbetweenmentalillnessdiagnosisofdepressionandworkplaceillnessofburnout?Wearestillexploringthat.Somesaycausative,otherssayassociative,stillotherssaytheyareoverlappingconditions,andsomesaythey’reessentiallythesamething.Perhapsthey’redifferentconditionsduetotheiraetiologyorcause,butmayresultinasimilarconstellationofsymptoms.Forexample,youcanhavedepressionandnotbeburnedoutbywork.Ontheotherhand,youcanbeabsolutelyburnedoutatworkandnothavetheDSM5diagnosisofmajordepression.Thisiswhysomepeoplefindthatachangeofworkenvironmentresultsinasignificantchangeofemotionalstateandengagementatwork.Thisiswhyadoctorwithdepressionthatiswellmanagedcanbeaneffectiveengagedworkerthatdelivershighstandardsofcare.ThisisexactlywhyweneedtotackletheissueofmandatoryreportinginsomeAustralianstates.Adoctorwithmentalillnessdoesnotequalanunsafedoctor.Adoctorwithmentalillnessmayprovideasafeandefficientcarejustthesameasadoctorwithcardiacorrespiratoryillness.

Thereisanelephantintheroomwe’vecalledmentalhealth.ButthereisanotherelephantsittingonthechestofourcliniciansthatIwouldcallinstitutionalhealth.Howdidwecometothis?Howdidwegetthebestandbrightest,theA-studentsinhighschoolanduniversity,theoneswhoworkedhardthroughschool,medicalschool,specialisttraining,howdidweendupthenwithdoctorswhoareburnedoutandreadytoquitmedicineorquitlifealtogether?

Someofyoumightthink“Oh,justtoughenupprincess.Iusedtodolongerhoursthanyou.”Perhapsthatistrue,butit’snotthedurationbutthequalityoftheworkthathaschangedovertime.Limitingworkhourshavemadenodifferencetoratesofburnout.Ourpatientsaregettingmorecomplex,new

diagnosesandtreatmentsarebeingdiscoveredeveryday,theadministratorsandlawyersareintrudingourworkspace.Inthepast,dailyworkmayhaveincludedahigherproportionofclinicalwork.Today,muchofourworkisnon-clinical.It’sdataentry,paperwork,organisational,research,etc.Weactuallyspendverylittletimewithpatients.Medicineisnolongerwhatitusedtobe.Youhavetologin27*timesbeforeyouseeapatientandchooseoneof273*algorithmsorprotocolsforyourpatient(*notrealdata).Thelinkbetweenworkplacestressorsandclinicianburnoutisconfirmedthroughseveralstudiesalready.

LastyearIburnedoutspectacularly.IwassnappyandIwasahorriblepersontobewithandworkwith.SolikeagoodGenerationXdoctor,Iwroteablog.ItitledittheDarkSideofDoctoring.TheblogwastriggeredbyasuicidedeathofaBrisbanegastroenterologistbutithitmehardbecauseIwasinadarkplace.Iwrotemostlytopendownmyemotions,butsomehowitwentviralandwasread288,000times.Thatis,morethanaquarterofamillionpeoplehavereadthatblog.AlotofclinicianssimplyidentifiedwiththefeelingsIhad.Thecontentwassimple.Ispokeaboutthe3thingsIlostduringmysurgicaltrainingandmylifeasasurgeon

Firstly:Lossofcontrol.Everydaymylifeisdictatedbyclinics,operatingtheatreandemergencies.Weareslavestoourpagersandoncallroster.EveryyearIgetmovedtodifferenthospitals.EverydayIampressuredtodomore.Iamtoldwheretobe,whattodoandwhotooperateon.

Secondly:Lossofsupport.Iwasstudyinganddidn’tseemyfamily.Imissoutonbirthdays,anniversaries,familyholidays.Ididn’thaveanyonetotalktobecauseeveryonewasbusy.NooneunderstoodthepressuresoftheworkIdo

Andfinally,butmostimportantly,Ihadalossofmeaning.Ilostthepurposeofmyworkbecauseitallbecameaburden.Whatreallymatters,patientcare,islostinthenoiseandbuzy-nessofwork.

Istartedsurgerywiththisideainmind,thatsurgerywasmyIkigai,aJapaneseconcept.WhatIlove,whattheworldneeds,whatIcangetpaidforandwhatI’mgoodat,alloverlappingandIfindmeaningthroughsurgeryatthecentre.Ilostallthat.Thetruthismanyofusinthisroomwouldknowthatsuchisthenoblecallingandpurposeofourwork.Butwelostit.Welostwhatmattered.Butitwasn’tasuddenthing.Itwasalwayssmalllittlethingsduringthedayovermanyyearsthatslowlypushuscloserandclosertotheedge.Thelossofcontrol,thelossofsupport,thelossofmeaning,theexams,theresearchdeadlines,thegenderinequity,thetoxicworkplace,thebullying,theresourcelimitations,everysmallthingbringsusclosertotheedgeofquitting.

Daily,chronic,repetitiveemotionalmicrotrauma.It’sliketheanalogyofthefrogintheboilingwater.Everymicrotraumaweexperienceeverydayisanotherdegreeuponthewatertemperature.Wecan’tkeeptrainingthefrogresilience.Itisnotenough.Weneedtofixtheboilingenvironment.Resilienceisapersonalsolution.Wemustdesigninstitutionalsolutionstoinstitutionalproblems.That’swhyholidaysaren’tenough.Wecan’tjustleavetheroomforabitandhopetheelephantswillgoaway.You’llbebackintheroomandstillfacethesameelephants.

Thegoodnewsisthatwecandosomethingaboutinstitutionalhealth.Butitwilltakeownershipoftheproblemsandcourageousleadershiptowardssolutions.Wemustgofrom“Theychangeortheydie”to“Wechangeorwedie.”Thisisourproblemashealthcarecommunityandweneedtofindpracticalsolutionsourselves.Otherinstitutionsarealreadyaheadinthisjourneyandhavegivenussomeideas:

ExecutiveLeadershipandPhysicianWell-being:NineOrganizationalStrategiestoPromoteEngagementandReduceBurnout.TaitD.Shanafelt,MD,andJohnH.Noseworthy,MD,CEO.MayoClinProc.2017;92(1):129-146.

Thispaperisamustreadforallofus,whetherornotweareinpositionsofleadership.Itprovidesmultiplepracticalwaysofmeasuringinstitutionalhealthandsuggests9keystrategiesontacklingthisissue.Resiliencetrainingisnumber8.Therestareaimedattheotherelephant.Thesolutionsareabsolutelypractical.Therearemeasurablegoalsforanydepartmentandinstitution.Iimploreyoutoreadthispaperthoroughly.Summarisingitherewillnotdojusticetotheexcellentpaperthatitis.Itprovidesmultiplepracticalmetricsoninstitutionalhealthandpracticalinterventionsonimprovingthosemetrics.Letmereiterate:itisamustread.

ThereisalreadyanationalframeworkonthematterofDoctorsandMentalHealth.TheANZCAhassomeclearplans.TheRACShavemadegreatstridesincreatinganActionPlanforCulturalChangeandLeadershipfromthetop.VariousHospitalsandDepartmentsaroundAustraliaandNewZealandareonactivediscussionaroundthisissue.Iabsolutelybelievethatthereisamomentumalreadyoccurringaroundthisissueandthatweareclosetotippingpoint.Iabsolutelybelievethat.

SowhatcanIdonow?WhatpracticalthingsshouldIdo?

HerecomestheActionPointsandhomework.Pleasethinkcarefullyaboutthese3Csandhowtheyapplytoyou,yourdepartmentandyourhospital.

1. CORE.Findyourcorebusiness.Whatisyourmeaningfulwork?Onewaytocombatburnoutistoensurethatyouaredoingenoughofworkthatyoufindmeaningful.Onefascinatingresearchdoneandexplainedinthesamepaperisthe20%rule.Evidencesuggeststhatdoctorswhospendatleast20%oftheirprofessionaleffortfocusedonthedimensionofworktheyfindmostmeaningfulareatdramaticallylowerriskforburnout(ShanafeltTD,WestCP,SloanJA,etal.Careerfitandburnoutamongacademicfaculty.ArchInternMed.2009;169(10):990-995).Althougheach1%reductionbelowthisthresholdincreasestheriskofburnout,thereisaceilingeffecttothisbenefitat20%(eg,spending50%ofyourtimeinthemostmeaningfulareaisassociatedwithsimilarratesofburnoutas20%).Thissuggeststhatdoctorswillspend80%oftheirtimedoingwhatInstitutionsneedthemtodoprovidedthattheyarespendingatleast20%oftheirtimeintheprofessionalactivitythatmotivatesthem.Thisactivitycouldinvolvecaringforspecifictypesofpatients(eg,thepoor,refugees)orpatientswithagivenhealthcondition(eg,becomingadiseaseexpert)oractivitiessuchaspatienteducation,qualityimprovementwork,communityoutreach,mentorship,teachingstudents/residents,orleadership/administration.Toharnessthisprinciple,youmustknowwhatthat20%activityissoyoucanfacilitateprofessionaldevelopmentinthatdimension.Findyourcoreandmodifyyourworkschedulestomeetthat.

2. CHAMPION.Findachampioninyourdepartment.Youdonothavetohavealeadershippositiontobeinfluentialinyourdepartment.It’samythtothinkthatyouneedtobeaunitLeadertomakeadifference.Findthewelfarechampionsinyourunit.Someonewhocouldbethewelfareofficertoinitiatesomeactionsforyourdepartment.Someonewhocouldkeepaneyeonmeasuringthe

institutionalhealthoftheunit.Thatpersoncouldbeyouorcouldbeyourcolleague.Tapthemontheshoulderandstartcomingupwithsimplecreativeideastoimprovethehealthoftheteam.UsethatShanafeltpaperasadiscussionprimerastheyhavecuratedandcreatedalistofmeasurableevidencebasedinterventions.Itdoesn’thavetobeexpensiveorextensive.Perhaps,youcanonedayevenformalisetheroleandhaveawellnessofficerineachunitresponsibleforthesematters.Notasocialsecretaryforbeer.Awellnessofficertoimprovethehealthoftheunit.

3. CULTURE.Thisisthebigone.Culturalchangewillrequireadepartmental,collegeandstateaction.Oneofthekeythingsinanyeffectivechangeisleadershipbuy-inandcommitment.Wearenotjusttalkingaboutthedepartmentalhead,buttheCEOortheheadoftheworkforcedepartment.Thiswillrequiresomelonger-termplans,butitisabsolutelypossibleanddoable.ThereisalreadyagoodmomentumandIbelievewearealmostattippingpoint.IcangivemultipleNorthAmericanexamplesofhowtopdownleadershiphasimprovedpatientcareandturnedhospitalsaroundbutIwillquotealocalexample.TheRoyalChildren’sHospitalMelbournehasstartedthisjourneyacoupleofyearsago.TheycameupwithanewClinicianCompact.Severalkeystatementsthatdefinethevaluesoftheorganisationarereiterated,likeapledge.Theystartedatthetoptoincludeallclinicalandadministrativestaff.Thiswastheirwayoftacklinganinstitutionalelephanttochangecultureandtoimprovethecareforeverychild.TheCollegeofSurgeonstoo,havedefinedaculturalchangecampaignwiththe“OperatingwithRespect”initiative.Wehavemomentum.Wecandothistodealwiththeinstitutionalhealthelephant.

NowtheelephantsinyourdepartmentsinMelbourne,AucklandorChristchurcharegoingtolookdifferent.Withthecurrentmomentumthatwealreadyhave,smallchangeswillmakebigdifferences.WecanbeginwithfindingourpersonalCorebusinessandmeaningfulworktoimproveourpersonaljobsatisfactionandefficacy.WecanthenfindChampionsinourdepartmentstoimprovetheunitwelfare.Wecantheninthelonger-termeffectculturalchangewithcollaboration.Dealingwiththeinstitutionalhealthwillgoalongwayinimprovingmentalhealth.Weneedtotacklethementalhealthandinstitutionalhealthelephantsatalllevels.Individualmentalhealthtreatmentapproaches,Departmentalactionplans,Hospitalculturalchangecampaigns,Statewideinitiatives,NationalpoliciesandCollegeleveldirectives.Multifactorialapproachestotheelephants.

Aproverbsays,“Onegenerationplantsthetrees,anothergetstheshade.”Seedhasbeenplanted.Momentumisalreadybuilt.Manyclinicianshavebeenworkinginthisarenaformanyyears.Thisgenerationandthenextwillgettheshade.

Weowethistoourpatients.Ourpatientsmatterandtheydeservementally&physicallyhealthydoctorsandhealthyinstitutions.

MrEricLevi,FRACS,MBBS(Melb),B.Sc,PGDipSurgAnat,MPH&TMSpecialistOtolaryngologist,Head&NeckSurgeonPaediatricENT,Head&Neck,AirwaySurgeon

ericlevi.com@DrEricLevi