I remember it as vividly as a childhood nightmare. The sense of vacuum when I’d go to the well and find nothing there. The deep-seated feelings of ineptitude for all things personal and professional. Exhaustion as thick as Appalachian fog.
I didn’t have a word for it at the time but I was experiencing burnout.
Burnout in healthcare has reached epidemic proportions. This isn’t hyperbole – according to the CDC’s Principles of Epidemiology, an epidemic refers to:
An increase, often sudden, in the number of cases above what is normally expected in [a] population.
Few would argue that the explosion of evidence around burnout in healthcare falls short of “a sudden increase.” In truth, the only part one could reasonably argue with is whether recent data are in fact an increase “above what is normally expected” or whether burnout has in fact been endemic but unmeasured in healthcare for centuries.
Things don’t start this way. It is common for caregivers of all kinds to describe having felt somehow “called to serve” a greater good in healthcare. They begin their careers as bright-eyed health professions students on any one of a number of different paths. I know – I was one.
Actually heeding that call however is no small task. Training is often grueling and can last well over a decade. To become a neonatologist I first spent 4 years in medical school, then 3 years in pediatric residency, then 3 more years in neonatal-perinatal fellowship for a grand total of 11 post-college years of medical education.
As a beneficiary of America’s medical trainee work-hours restrictions my stories aren’t nearly as insane as those who trained before me, but here are just a few to provide some insight into what “grueling” looks like in real life:
On one medical school clerkship I worked 12-14 hours a day for 26 days straight (a privilege for which I paid over $60,000 in tuition/fees that year).
- My longest week in the hospital as a trainee after medical school lasted 95 hours – two 30 hour “full calls,” one 24 hour “weekend call” and one “regular” 10-hour weekday.
- As a resident I started listening to books on CD (in the days before Audible) while driving home so I could be certain I hadn’t fallen asleep at stop lights.
After training the challenges do not relent as our nurses, therapists, physicians and surgeons are met after commencement with:
- Equally grueling ongoing work schedules as full-fledged professionals,
- An ever-changing and increasingly hyper-regulated work environment,
- Crushing student loan debt that ranges from $30,000 for bachelors-prepared nurses to well over $170,000 for physicians, and
- An American healthcare system that neither consistently supports nor nurtures personal or professional resiliency.
Layer these challenges onto a field that by its nature demands an emotional well markedly deeper than most (see On Hubris and Humility) and one wonders why it’s taken until now for burnout in healthcare to hit the national consciousness.
So what’s the answer?
Tasting the bitterness of burnout has made me a strong supporter of efforts to both prevent it and to help others coping with its necrotic effects. I’ve also come to believe that there is no one “fix”– rather, turning the tide against burnout will require building caregivers a moat of resiliency that has at least three layers of defense – one that supports our work, one that supports our teams, and one that supports ourselves.
Any one of these layers is individually necessary but insufficient to keep burnout from storming the castle walls. But as a triumvirate they can become nearly impenetrable.
Layer 1 – Teaching, Resourcing, and Empowering Continuous Improvement
In the outermost ring, we must inculcate continuous improvement into every aspect of caregivers’ work, an effort Mission Health is driving through Mission reNEW. The ability to directly influence our daily work is deeply linked to magnifying joy at work, and joy is a powerful deterrent to burnout.
But continuous improvement is like fishing – to become a great fisherman you first must have some understanding that you need to fish. Then you need a fishing pole and someone to teach you how to use it. Finally, you need to be empowered to actually go fishing and receive some recognition when you catch something.
While continuous improvement methodologies have permeated healthcare for years, few centers can say that every caregiver everyday has the combination of tools, teaching, and empowerment to make continuous improvement an integral part of his or her everyday work. As leaders we can and must change this.
Layer 2 – Amplifying the Power of Teams
Moving further inward, the next layer of our defense must magnify the power of “belonging” to a team. I’ve been on many teams in nearly 20 years in healthcare, from the Worcester Medical Center ER team where I got my start as an ER technician to Mission Health’s senior leadership and NICU follow-up clinic teams today. The best teams have reminded me of playing sports as a kid. I was a baseball player, and anyone who played little league (or any kids recreational sport for that matter) remembers a game when the whole team pulled together, motivating each other to perform well beyond each player’s baseline potential and, under the most exigent circumstances, reached for and grasped improbable success.
We’re all at still little-leaguers at heart, and the team bond is no less powerful now then it was when we wore rally caps and screamed “hey batter batter” at the tops of our lungs. Visionaries like Marcus Buckingham have recognized this and are facilitating better teamwork through strengths-based programs like TMBC’s StandOut (a program Mission has had in place for over a year with some exceptional results).
I strongly anticipate that before the decade closes programs like these that tap into the resiliency-building power of teamwork will be essential to any leading health system’s arsenal to prevent and combat burnout.
Layer 3 – Nurturing Personal Wellbeing
In perhaps the greatest commencement speech in history, President Kennedy told the graduates of American University in the summer of 1963 that:
…in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s future. And we are all mortal.
At our core all caregivers are just people. People who come to healthcare with our own stories and our own scars. We are only human and as humans we must support and nurture each other’s personal wellbeing with the same intensity we use to build any other layer of defense against burnout.
Enormous bodies of research have shown that personal wellbeing is a muscle we can consciously strengthen over time. As an industry we’ve barely scratched the surface on ways we can support the growth and development of this muscle in each of our caregivers. Mission has partnered with the Life-XT team to pilot their combination of techniques from the book Start Here (basically the programmatic equivalent of P90X® for personal wellbeing). Other early-days thought leaders in evidence-based personal wellbeing include Bryan Sexton and his “WISER” work at Duke and Albert Wu’s “Caring for the Caregiver” efforts at Hopkins.
We cannot shy away from this intensely personal but intensely important work – without it we ignore the most powerful and last line of defense against burnout.
In one of my favorite episodes of The West Wing (S2-E10: Noël), Leo tells Josh a story about a man who fell in a hole:
This guy’s walking down the street when he falls in a hole. The walls are so steep he can’t get out. A doctor passes by and the guy shouts up, ‘Hey you. Can you help me out?’ The doctor writes a prescription, throws it down in the hole and moves on. Then a priest comes along and the guy shouts up, ‘Father, I’m down in this hole can you help me out?’ The priest writes out a prayer, throws it down in the hole and moves on. Then a friend walks by, ‘Hey, Joe, it’s me can you help me out?’ And the friend jumps in the hole. Our guy says, ‘Are you stupid? Now we’re both down here.’ The friend says, ‘Yeah, but I’ve been down here before and I know the way out.’
Caregivers experiencing burnout need a friend who’s been there and knows the way out. They need supportive leaders and systems that surround them with conscious and unconscious lines of defense against the attacking troops. Their plight needs to be dragged out of the darkness and into the light.
Beating back burnout in healthcare will demand purposeful efforts to build our caregivers a deep moat of resiliency. Resourcing must span all three layers of defense in order to ensure bulwarks won’t breach. And caregivers can’t build it alone – we must come together as a community of patients, providers, advocates and leaders to build it for each other.
If not now – when?
If not us – who?
We are worth the investment.