Healing the Healers

INSTITUTION, HEAL THYSELF

For the past several years, leaders at the University of Kansas Medical Center have been working, in collaboration with The University of Kansas Health System and The University of Kansas Physicians, to help promote more work-life integration, a healthy work environment and, ultimately, wellness for the professionals who protect the health of the rest of us.

In 2017, Leland Graves, M.D., then president of the faculty council, presented the results of a wellness survey conducted among physicians and non-physician faculty at the KU School of Medicine faculty retreat. The survey was composed of an abbreviated form of the Maslach Burnout Index, the standard instrument used to measure burnout, as well as the Expanded WellBeing Index for Physicians, to assess work-life integration and meaning in work.

The survey indicated that the rate of burnout among all faculty at the KU School of Medicine is lower than it is for physicians nationwide, and that 86% percent find their work meaningful. But there were also concerns. Between 53% and 61% of faculty ages 35 to 55 were at high risk for burnout. And nearly 40% of all faculty disagreed with the statement, “My work schedule leaves enough time for my personal/family life.”

Some of the trouble spots revealed were predictable: clinicians cited the volume of patient care and dealing with electronic medical records (EMR) as top stressors, while researchers cited securing funding. As they are around the country, burnout rates were higher for women, who shoulder more domestic responsibilities at home on top of their careers. “In addition, women tend to spend more time with their patients, which is not always accommodated in clinical scheduling, and frequently are dealing with issues of gender bias,” said Kim Templeton, M.D., professor of orthopedic surgery at KU Medical Center and nationally known expert on gender differences in burnout.

The biggest organizational culture problem the respondents identified was leadership, especially leadership that communicated poorly or failed to recognize good work. Godfrey noted that research shows that good leadership is especially critical for nurses; strong nurse managers are associated with healthy work environments as well as better health outcomes for patients.

Those surveyed also complained about not feeling like they had enough autonomy to be able to change processes that needed fixing or even to control to their own schedules.

“People who work in academia are problem solvers, independent thinkers,” said Jeff Radel, Ph.D., associate dean for academic and student affairs in the Department of Occupational Therapy Education at the KU School of Health Professions. “Burnout is more than just a workload thing. It’s also about, am I valued, and am I part of a community where my perspectives are considered?”

“There’s an awareness now about the problem. And we have a sense of its various components, of pre-burnout and burnout,” said Tsue. “But we’ve got a lot of work to do. Changing culture takes time.”

IT’S THE SYSTEM

A guest speaker at that 2017 faculty retreat was Tait Shanafelt, M.D., Stanford’s chief wellness officer, the first such position at an academic medical center designed to improve clinician well-being.

Twenty years ago, when he a senior resident at the University of Washington, Shanafelt started questioning the culture of medicine when he noticed other residents becoming cynical.

“I remember observing the distress among the interns on the team, their reaction to another admission and even some of the things they would say,” he said in a 2019 video interview. “The way they were reviewing their work or viewing patients was in some ways just incongruent with what I knew they stood for as people and why they went into medicine.”

In the early 2000s, Shanafelt published the first study connecting clinician well-being and quality of care and became a major thought-leader on burnout.

Many contributors to burnout are the result of systemic changes to health care. EMR systems, which replaced paper patient charts and are mandated by federal law, are often so large and cumbersome that they gave rise to the term “pajama time” to describe the hours providers spend feeding information into them at home after dinner. And then there’s the way physicians are paid now, not with a salary but according to a fee-for-service methodology created by Medicare that rewards them for doing more procedures and seeing more patients rather than the amount and quality of time that they spend with patients.

But in those early days, burnout was thought of largely as an individual problem requiring individual solutions. People were encouraged to get more exercise, meditate, do yoga and attend workshops and webinars on stress management, all with the goal of improving their own personal resilience.

These sorts of programs are offered to residents, as well as all students at KU Medical Center, through the Counseling and Educational Support Services office. And they can be very helpful coping mechanisms.

What they cannot do is address systemic root problems, such as high nurse-to-patient staffing ratios, cumbersome EMR systems, fierce competition for research funding and a national model of compensating physicians that rewards quantity of services rather than quality of care.

Even the word burnout implies that the problem is the individual’s failing, which is one reason that many, including Godfrey, prefer to frame the issue more positively in terms of clinician well-being.

After all, people who go into medical fields are already a relatively tough bunch. Just getting into school and surviving the training takes more than a little resilience. The same is true for laboratory scientists, employed at academic medical centers to conduct the basic research behind new drugs and treatments. Many of these scientists never treat patients, but they’re also at risk for burnout, largely because of the intense pressures of getting their research funded.

Consider the tenacity of a basic scientist such as Tomoo Iwakuma, M.D., Ph.D., a professor in the Department of Cancer Biology at KU Medical Center.

Before he became a researcher, Iwakuma was an orthopedic surgeon treating bone and soft tissue cancer patients in Japan. Too many times, he watched patients die when there were no more treatment options.

“I couldn’t stand it,” he said. “Doctors are supposed to help cure the patient. I wanted to be able to give hope to the patient. That’s my dream.”

Iwakuma gave up his relatively lucrative career, earned a doctorate in molecular genetics and took a job at Louisiana State University so he could do the research necessary to create new treatments.

As a basic scientist, he would have to come up with his own grant money in order to fund his research — and not only to cover the cost of equipment and materials, but also the salaries of the people in his lab and a portion of his own. This is a fact of life for researchers at virtually all academic medical institutions in the United States. The most common federal grant for a biomedical research project is a 3- to 5-year award from the National Institutes of Health known as an R01 grant. Securing one is a crucial milestone in a researcher’s career. Iwakuma knew that if he didn’t get an R01, his research career would eventually end.

Right after Iwakuma started at Louisiana State, disaster struck, literally: Hurricane Katrina, which shut down the university for eight months. Even when he returned to the lab, the freezers were full of mold, some of the equipment wasn’t working and the lab wasn’t fully functional for many more months. But Iwakuma pushed on.

His first two R01 grant applications were denied funding, which is not uncommon, he said. But then the global financial crisis of 2007-08 hit, the economy tanked and federal research funding was slashed. Only 10-15% of applications for R01 grants were funded during that time. But Iwakuma persevered. If he didn’t, he would not only lose his dream, he would lose his job. So he revised his application, only to be denied again. And again.

“I started asking, ‘Am I suited to be a researcher?’” he remembered. “I even started thinking about going back to Japan.”

Iwakuma believes he was burned out, but somehow, he muscled his way through. In 2013, eight years after his first application and his fifth try, the NIH awarded Iwakuma his first R01 grant.

“I cried. My wife cried, too,” said Iwakuma, now the Frank B. Tyler Cancer Research Professor in the KU School of Medicine. “I had many friends who lost their jobs because they couldn’t get that first R01. I was really lucky.”

INTERVENING EARLY

Academic medical centers have a unique responsibility to address burnout not just for their employees, but for the future health care providers and scientists they train. Burnout has been documented among nursing and medical students; the 2019 National Academy of Medicine report stated that burnout ranges between 45 and 60 percent for medical students and residents. Intervening during these phases of their education not only protects their health, it also helps set work values they will carry over into their careers. At KU Medical Center, the Office of Graduate Medical Education (GME) manages 58 residency and fellowship programs that train those future providers.

Since Korentager’s and Tsue’s days as residents, the Accreditation Council for Graduate Medical Education, the national organization that accredits all U.S. graduate medical training programs for physicians, has limited the number of hours a resident can work to 80 hours a week, with no more than 24 consecutive hours on-call. The GME office at KU Medical Center monitors those hours for violations and tries to identify anyone working long hours who might be on edge. But there are no data to indicate that burnout rates have improved since the work-hour regulations were put into place, noted Templeton, indicating that other issues need to be addressed. For example, residents are also now being encouraged to report any harassment or abuse they experience, including by superiors.

And for the last five years, GME has been administering their own wellness survey among residents. In response to the answers they’ve received, they’ve made some concrete changes to make residents’ lives easier, said Greg Unruh, M.D., associate dean for GME.

Those changes include closer, more convenient parking; memberships to KU Medical Center’s Kirmeyer Fitness Center; and pay increases and standardized benefits packages across departments.

At Templeton’s suggestion, Unruh is also working with Larry Long, Ph.D., assistant vice chancellor for student affairs and director of Counseling and Educational Support Services, to develop focus groups for female residents, who have reported more burnout than male residents, largely because of gender bias and shouldering more domestic responsibilities.

“What we are hearing is that it is traditional societal norms,” said Unruh. “They still feel responsible for the laundry, making sure the kitchen is clean, and that’s stressing them out. And if a resident has kids, that’s a big stressor — especially for the females.”

The GME office has also arranged for residents to be able to use, free of charge, the same counseling services available to medical students. Thirteen residency programs have chosen to automatically schedule all their new residents to meet with a psychologist at the counseling office to discuss how they plan to take care of themselves during their residencies.

In the three years these initial onboarding wellness visits have existed, only 4% of new residents have opted out of this visit, Long said.

That statistic doesn’t surprise Becky Lowry, M.D., associate program director for the internal medicine residency.

“When we have medical students interview for residency program jobs, they’re savvy, they’re bright, and they ask about initiatives related to wellness,” she said. “They’re aware that this is a national epidemic and that we need to be responding to it in an effective manner.”

TAKING ACTION

Along with Tsue, Long, Graves and Akinlolu Ojo, M.D., executive dean of the KU School of Medicine, Lowry is part of the Physician and Provider Engagement and Wellness Steering Committee formed in 2018. Using the results of the faculty council and GME surveys, town halls and listening tours as well as national studies on burnout, they’ve formed “design teams” organized around six areas to promote well-being: community at work, EMR efficiency, wellness, alignment of individual and organizational culture, communications, and the integration of work and life.

The design team tasked with improving the efficiency of the EMR is testing a redesigned EMR in one clinical department. Meanwhile, another team is launching a flexible scheduling system to give clinicians more input and flexibility with schedules. If all goes well, the plan is to expand these efforts into other departments. Sometimes, the solutions can be simple: they’re also exploring creating a larger physicians’ lounge to foster a sense of community at work, the lack of which is a known factor in burnout.

The University of Kansas Health System has also contracted with Bright Horizons, a company that provides backup childcare and eldercare, in addition to pet care and housekeeping, at negotiated rates for employees whose arrangements fall through or need extra help.

Meanwhile, in January 2019, the medical center launched Leadership by Design, a program to develop leaders who actively engage in practices designed to prevent burnout. Faculty also take leadership behavior surveys annually that produce a score that indicates the likelihood of burnout in a given department.

“This allows us, when scores suggest burnout, to interact with the chair to discuss results and to identify and change any concerning behaviors,” said Peter Smith, Ph.D., senior associate dean for research and senior associate vice chancellor for research at KU Medical Center.

In March 2020, when the coronavirus pandemic reached Kansas, it forced the health system and medical center to ramp up their wellness efforts order to deal with the stresses and anxiety of treating patients with COVID-19. Health care team members were given access to a hotline so that they could be seen by a primary doctor quickly if they needed treatment for any type of illness. A resiliency and support webpage was created that listed resources for different types of psychological care, grocery delivery services and online exercise and meditation programs. Grab-and-go arrangements were made with local restaurants so that employees could pick up their orders in the hospital cafeteria rather than having to stop on their way home. Plans are also being considered for a wellness center for faculty, similar to the one for residents and students. There are no plans to discontinue these initiatives when the pandemic is over, Lowry said.

"We need to be making changes within the culture, within the bigger system, about things related to health systems, the way physicians are paid, the government, insurance companies... Some of those things require tough conversations, but they are the big conversations we need to have."

- Richard Korentager, M.D. Plastic Surgeon Chair, Department of Plastic Surgery, KU School of Medicine

Meanwhile, Templeton is co-leading a national effort, based on work she has already completed successfully in Kansas, to change the language in medical licensure applications to omit questions about specific health problems so that physicians feel free to seek help, especially during the stress of the pandemic.

In September 2020, a new Medscape study found that nearly two-thirds of U.S. doctors reported intensifying levels of burnout since the coronavirus pandemic began, and nearly half said they were also lonelier because of social distancing and stay-at-home guidelines. Among female physicians in the study, nearly 70% said their burnout had worsened, compared with 61% of male physicians, as they juggle caring for children who are learning remotely while maintaining a full workload as a doctor.

But even when the pandemic subsides — when people in Karen Little’s situation have resources for their problem on campus — there will still be work to do. Burnout is a problem that extends beyond any public health crisis, any one individual or any one institution.

“We need to be making changes within the culture, within the bigger system, about things related to health systems, the way physicians are paid, the government, insurance companies,” said Korentager. “Some of those things require tough conversations, but they are the big conversations we need to have.”