In the video below, I discuss the importance of peer support for health care workers, and why I became a volunteer for the Betsy Lehman Center’s new statewide Virtual Peer Support Network.
In healthcare, exposure to sickness, dying, and death are a feature of the job. It is normal for clinicians to sometimes feel burnout, stress or suffer because of an adverse outcome, whether it’s work related, perhaps due to unexpected patient harm, or personal, such as a divorce or loss of a loved one. These feelings are are not weaknesses. They are normal parts of being a human being and speaking with someone else about it can actually help. That’s what the Betsy Lehman Center Virtual Peer Support Network program is all about, and why I’m part of it.
The Virtual Peer Support Network is a free service that connects colleagues in the Massachusetts medical community with peers who are trained to help with the difficult feelings that can accompany working on the front lines of health care. Peer supporters are volunteers who provide encouragement, support and resources to colleagues. All conversations are confidential. The Betsy Lehman Center will connect healthcare workers with a trained peer supporter who works in a similar role. For example, physicians support physicians, nurses support nurses, etc.
Individuals who want to talk to a peer supporter can complete this request form or call 617-701-8101 to reach someone at the Betsy Lehman Center.
While the causes of physician burnout (and clinician burnout more generally) are multifactorial, inefficient electronic medical records (EHRs) and their associated disrupted workflows consistently top the list of the main drivers of physician burnout. Atul Gawande wrote an eloquent piece on the subject entitled, Why doctors Hate Their Computers, in which Dr. Gawande notes “I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.”
There are EHR optimization pearls your organization can take.
But there are practical EHR optimization pearls any organization can take to reduce administrivia driven burnout. Last week, I co-authored a paper for the Joint Massachusetts Medical Society (MMS) – Massachusetts Health & Hospital Association (MHA) Task Force on Physician Burnout in partnership with the Reliant Medical Group: Changing the EHR from a Liability to an Asset to Reduce Physician Burnout.
This paper includes more than a dozen electronic health record (EHR) optimization techniques organizations can take today to improve the usability of the EHR as well as its associated workflows, in order to reduce unnecessary administrative burden for physicians and other clinicians.
Our message is that there are many interventions compassionate leaders can take today to help mitigate the drivers of clinician burnout. We would be happy to hear what has worked for you.
Each year, the graduating classes of three average size medical schools don’t add a single physician to the US workforce; they simply replace the 300 to 400 physicians the American Foundation for Suicide Prevention estimates kill themselves each year. We lose a doctor a day to suicide.
In a recent blog
post a healthcare CEO asked, “Is the rate of physician suicide
statistically different from that of other highly paid
professionals?” Yes.
The American
Psychiatric Association reported that physicians have the highest
suicide rate of any profession at their annual
meeting in 2018, higher in fact than active duty military personnel.
The time to prevent
physician suicide, rigorously document its occurrence, remove the
stigma of seeking mental health care and to care for suicide victims’
workplace survivors is long overdue.
Physicians know how
to stay healthy. This is why it is especially tragic that the only
cause of death where the risk to physicians is higher than the
general public is suicide.
Worse, we’ve
been aware of this slow motion tragedy for generations and it is
largely preventable. S. Dana Hubbard, M. D., Director, Bureau of
Public Health Education, New York City Department of Health published
the fact that physicians lead the list of suicides by professions in
the American Journal of Public Health, in 1922.
Almost a century
later mystery still shrouds the exact number of physician suicides
each year as families and employers alike are reluctant to tell the
truth in public, due to the fear of stigma. Medical examiners may
have difficulty distinguishing intentional from unintentional
traumatic deaths. Even when a suicide is accurately determined, there
is no consistent reporting of the victim’s occupation.
Most experts agree the physician suicide rate is roughly twice that of the US population in general, and it is even worse for female physicians. A meta-analysis of physician suicide published in the American Journal of psychiatry demonstrated that both male and females physicians are more likely to die by suicide compared to the general population (1.41 times more likely for male physicians and 2.27 times more likely for female physicians).
The
US healthcare system is killing physicians.
Students and young Physicians have been documented to be actually more resilient and less depressed than the US average. Then we are subjected to stress, moral distress and trained to ignore the symptoms of depression until it is too late. A study published in the Archives of General Psychiatry demonstrated that the rate of depression among physicians immediately prior to entering internship was 3.9%. During internship, this rate skyrocketed to 25.7%.
Factors contributing
to the epidemic of physician suicide include:
Repetitive
exposure to death and dying
Exact knowledge
of (and ready access to) lethal means
Stigma
associated with asking for mental healthcare and
Our
profession’s excessive dependence on self-reliance.
While the first two
factors above are likely inherent to the profession, the latter
two factors driving suicide are amenable to mitigation.
Here are Ten Suggestions for 2019:
Put an end to the silent curriculum (“Don’t ask for help. Never show weakness.”) in physician training programs.
Part of the reason
physicians don’t ask for help is that in training we were taught
the unwritten rule: “Don’t ask for help and never show
weakness.”
On my first day of surgical internship, I was naturally a bit apprehensive, given the enormous privilege and responsibility I was about to be given, caring for, and operating on some of the most ill patients in one of the finest academic medical centers in the US. I was shocked and taken aback by the advice the entire group of us surgical interns were given by the senior attending surgeon, tasked with orienting us. He said, “Always remember that while you are here… you are swimming with sharks. So don’t make waves, and if you are bit, don’t bleed.” It is this kind of abusive attitude which I am confident cost one of my female classmates her life, during her surgical residency when she killed herself halfway across the country in another surgical training program.
We must incorporate wellness into both the written (and silent) curriculum.
2. The Physicians need better access to mental health care without fear of punishment for admitting they need help.
Dr. Michell
Hardison, a well-respected family doctor in Raleigh NC chose suicide
over psychiatric care for his depression. His daughter
Anna Hardison Severn revealed, “He was 100% positive that if he
came forward and said he needed help that there would be a reprisal
of some kind.”
State medical boards
are responsible for licensing physicians and protecting the public by
ensuring physicians meet high standards. There is nothing wrong with
medical boards asking physicians if they have a medical or
psychiatric condition which might lower the quality of the care they
deliver. They should not however ask if a physician has ever been
under the care of a mental health professional. For if they do
this, physicians will forgo needed care which could harm the doctor
and jeopardize the quality of the care for their patients.
The Federation of State Medical Boards (FSMB) Workgroup on Physician Wellness and Burnout made 35 recommendations to better address physician burnout. These recommendations should be adopted by all states. They advise against asking probing personal questions regarding a physician’s mental health. The FSMB specifically recommended that state medical boards indicate“it is not only normal but anticipated and acceptable for a physician to feel overwhelmed from time to time and to seek help when appropriate.”
3. Not only should the electronic medical record must be optimized, but processes and systems must be optimized in order to get the most out of this technology and improve user satisfaction.
How it is that
healthcare is the only industry where digitization/computerization
has decreased worker productivity? The epidemic of physician
burnout, driven by administrative hassles, loss of professional
autonomy and increasing workloads is contributing to physician
burnout, depression and suicide.
It is inexcusable
that for every hour physicians spend facing a patient in their
office, they
are forced to spend two hours tending to desk work and
documentation in the electronic medical record.
At UC Davis Medical Health, Scott MacDonald, MD, FACEP demonstrated that by optimizing their electronic medical record’s use, the health system could both dramatically increase physician satisfaction with their EHR and improve their quality of life. They were able to eliminate over 25 hours of unproductive, unnecessary busy work from their physicians’ schedule each month! Imagine how much more time physicians could spend meaningfully caring for their patients and achieving work life balance if this innovation were to be adopted nationwide.
4. Stop the stigma. Employers of physicians, including hospitals, physician groups and residencies must encourage and normalize accessing mental health care.
We must destigmatize and treat physician depression in order to prevent suicide. One study found that access to residency positions was limited for fully qualified students who had requested psychiatric counseling! Only when seeking out a councilor is considered “normal” will physicians ask for help when they need it. All too often, physicians are encouraged to keep vulnerabilities hidden and not ask for help.
5. The practice of requiring medical students and residents to obtain mental health care at their own institution limits confidentiality and should be eliminated.
Until the stigma of obtaining mental health is completely relegated to the ash-bin of history, the confidentiality of accessing such services is critical, particularly for physicians in training. Some student and resident health plans require trainees to obtain healthcare at their own institution, limiting confidentiality for both physical and psychiatric conditions. This paternalistic and antiquated requirement should be eliminated.
6. Peer support should be available at times of great vulnerability:
Medical errors,
patient injuries and patient deaths are obviously painful for the
patient’s families. Less well understood is the fact that
physicians also suffer emotionally in such circumstances,
particularly if they believe they have somehow failed their patient
and begin to second-guess their own competence.
In times of great stress, such as these or when facing a medical malpractice lawsuit, physicians are extra vulnerable to depression and suicide. It is at these times that confidential peer support, advice from a colleague who has endured the same stressor is most helpful. Employers should plan ahead for such events and offer well-structured and readily available confidential peer to peer support programs to their employed and affiliated physicians.
7. We must accurately keep track of suicide rates by profession. State medical examiners should record the occupation of all suicide victims, including what school they are attending if they are in college or graduate school.
Only then can we
identify opportunities for improvement and evaluate whether our
interventions are effective in stemming the tide of this horrific
slow motion tragedy.
This would capture both the number of physicians / medical students who are committing suicide, and also spotlight any outlier institutions.
8. Postvention: Care for the bystanders after a physician suicide is essential.
Post-suicide counseling and peer support is especially important after a colleague has committed suicide. Toolkits such as the American Foundation for Suicide Prevention’s toolkits are available on line. There is even a toolkit specifically designed for medical schools to utilize after a medical student suicide.
9. Encourage all physicians to select their own trusted primary care physician (and regularly check in with that physician).
All too often physicians follow the dictum, “physician heal thyself.” Employers and affiliated institutions should encourage all medical students, residents and practicing physicians to choose their own trusted primary care physician. In addition to obtaining objective evidence based care from a personal physician, these trusted doctors represent another touch point from which distressed physicians can obtain emotional support.
10. Accessing medical care, whether physical or psychiatric, should be modeled by mentor physicians.
Organizational
leaders should model self-care, access mental health care publicly
and publicly reinforce the necessity of a healthy work-life balance.
Together we can
end the epidemic of physician suicide. Let’s make it happen in
2019.