Tips for workplace wellness

The need for wellness in medicine is undeniable during “the hangover of COVID that we're living through right now,” said Lisa Ellis, MD, MS, MACP, during a session for early career physicians at Internal Medicine Meeting 2023.

“In our homes, we're all talking about wellness and burnout. These are now household words, they're on the news, they're in every newspaper,” she said.

Most physicians are facing burnout. The latest data show that nearly 63% of physicians report one or more of its signs (e.g., emotional exhaustion, depersonalization, lack of sleep) at least once per week, said co-presenter Ankita Sagar, MD, MPH, FACP.

Many physicians are also planning big changes to their work. “Most recently, one in three physicians intended to reduce [clinical] work hours in the next 12 months,” she said. “And this data is from 2021, so the 12 months have already passed.”

Also in 2021, one in five physicians reported they intended to leave the practice of clinical medicine altogether in the next 24 months, Dr. Sagar said. “We are approaching that 24-month mark. So when I think about our residents, our fellows, our early careers … [more and more] are intending to do nonclinical work as the majority of their [full-time equivalent],” she said. “Now we can understand why we are projecting a workforce shortage.”

But these shakeups aren't just occurring at the individual physician level. Hospital CEO exits hit a four-year high in January, with the 23 departures announced that month representing the highest CEO turnover across 29 industries, according to a February report from executive coaching firm Challenger, Gray & Christmas.

“It's not just the chaos on the frontline. It's coming top-down, all around. It's like a starburst,” said Dr. Sagar, Chair-elect of ACP's Council of Early Career Physicians and an associate clinical professor of medicine at Creighton University School of Medicine in Omaha, Neb. “And it's important to understand that burnt-out leaders are now the leaders of other burnt-out leaders.”

For many years, internal medicine leaders have discussed the need to prioritize wellness, said Dr. Ellis, who is an associate professor of internal medicine and OB-GYN and executive director for provider and trainee wellness at Virginia Commonwealth University School of Medicine in Richmond, Va.

“For a long period of time, we looked at this from the individual initiative level, then we looked at it from the departmental and organizational/systems levels,” she said. “And we're hoping to be able to show to you today how we can look at this as a change in culture, which is not always the easiest thing for us to do.”

During their session, “Everyone Is a Leader in Transforming the Culture of Medicine,” they offered the following advice, framed within “wellness-gone-bad” cases.

1. Inclusivity in problem solving

In the first case, a group of internal medicine physicians subspecializing in nephrology practiced in a set of about 16 rooms. Their organization announced a mandate requiring all clinic sessions to be held in four-hour segments: 8 a.m. to noon and 1 to 5 p.m.—no partial sessions, no exceptions.

The policy was at odds with the timing of the physicians' other activities, which included grand rounds meetings, medical director meetings, clinical faculty meetings, and teaching classes. “That's the first thing that kind of knocks us around a little bit in wellness is overregulated mandates. … We've had plenty of studies that tell us if you take away people's control, no matter how small it is, you've got much more of a concern for burnout with those people,” Dr. Ellis said.

A physician who worked at the clinic asked administrators what problem they were trying to solve with the new schedule policy. The administrators called it a “brick-and-mortar” problem: They wanted to fill their clinic rooms and utilize their nurses. However, they had not involved the physicians in helping to solve the problem.

They used a fishbone cause-and-effect diagram as a tool for the discussion, with the final “effect” box dictating the goal (filling the rooms during those hours) and the “cause” boxes outlining the environment, the people involved, and the necessary materials, methods, and equipment to address the problem, Dr. Ellis explained. Now everyone who needed to be involved was invited to discuss further.

The physicians offered a different solution, working out everyone's preferred schedule while ensuring coverage during those times. “Once they figured it out and they got to do what they wanted, and it was working, they not only filled the rooms, but they overfilled the rooms because they were determined to make this work,” said Dr. Ellis.

The result was a win-win for everyone: The administrators got the rooms filled, and the physicians had control over their own work schedules and even experienced higher job satisfaction, she said. “The culture change is the wider overview that generalizes into not just changing that one policy, but a message by solving problems this way. Then the message to the organization was ‘We believe in being inclusive, and that's why we want to sit at the table with you,’” she said.

2. Caring for team members

In the next case, a hospitalist requested a call with her team leader to discuss the hospital's credentialing application and how it could be improved. “She's concerned about the language used in the application, as it may be a barrier to physicians seeking care,” said Dr. Sagar, who is also system vice president for clinical standards and variation reduction at CommonSpirit Health.

Questions in the credentialing application included: Have you ever incurred or suffered any chronic illness or physical injury? Are you currently engaged in the illegal use of drugs? Have you ever been evaluated or recommended for treatment, diagnosed with, or treated for alcohol, narcotics, or any other substance abuse, sexual addiction, or mental illness? Is there any reason why you would not be able to carry the obligations and prerogatives of the professional position?

While some may think regulatory bodies require these questions, that is not the case, Dr. Sagar said. ACP, the American Medical Association, the Federation of State Medical Boards, and The Joint Commission have all said that administrators should refrain from asking these types of questions, she noted.

To underscore how these questions create barriers to clinicians seeking help, Dr. Sagar reviewed the results of this year's Medscape report on physician burnout and depression. “They had 9,100 physicians surveyed across 29 specialties,” she said. “Internal medicine scored the second highest on rates of burnout at 60%, only second to emergency medicine.”

The report asked physicians with symptoms of burnout and depression if they've sought help and, if not, why not. “This is what they found: 42% of the physicians surveyed said, ‘I worry that people will think less of me and my professional abilities,’ ‘I fear that my medical board or my employer will find out,’ and ‘I worry that people will think less of me,’” Dr. Sagar said.

Dr. Ellis offered a real-world example of the harms of asking physicians if they've ever received any counseling or mental health help. A colleague who replied yes to the question asking if they had ever received mental health services immediately received calls from the credentialing office and was pulled from clinic for three months while third-party payers gathered the colleague's private counseling documentation to make sure there was no risk or harm to patients while they were practicing.

“I said, ‘So you checked that box saying yes,’ and my colleague said, ‘My mother passed away in the last two years, and I went to a bereavement counselor, so I just put yes down,’” Dr. Ellis recalled. “And the colleague said, ‘I will never put yes down again.’”

Dr. Sagar noted the appalled faces in the audience. “You're like, ‘I want to do something,’” she said, adding that ACP's advocacy toolkit offers a clear path for action, with template letters and PowerPoint slides that are adaptable to local efforts. “The culture change is, we want our medical staff to come forward to seek help.”

3. Listening and asking proactively

In the third case, many clinicians were leaving their organization. “It became contagious, and people were leaving in droves,” Dr. Ellis said. “And when this information got to the senior leaders and board … the first questions that they asked were right along the same language as the tool of the ‘Five Whys,’ which is used in process improvement.”

When asked why the clinicians left, human resources staff noted that they had completed only some of the exit surveys. “But the ones that they got to said people wanted part time and different hours, and they wanted a different percentage of being full time or not,” Dr. Ellis said. “And that's something that this organization did not do.”

Why did the clinicians want this? They needed more flexibility after COVID-19 due to a lack of child care or caring for sick family members. Why couldn't they have that flexibility? They had no control or input into alternative working hours because the organization didn't offer it. Why not? There were existing policies on work hours and no part-time physicians. For the fifth and final why, the answer was that the policies hadn't been reviewed or discussed with stakeholders to update them to do things differently.

Then someone questioned why the organization does exit surveys, rather than asking more proactive questions. “We started to think about why would we not do intention-to-stay surveys, and why would we not ask questions that would perhaps give us trends with issues before people left?” Dr. Ellis said.

Such questions could include: What do you like most about working here? If you could change something about your job, what would it be? If still working in two years, do you think it will still be in this organization? What tempts you to leave? When the organization sent out an intention-to-stay survey, it received more than 2,400 responses in 24 hours, Dr. Ellis said.

In addition, the board called the clinicians who had left because they couldn't work part time and offered to bring them back and figure out how they could. About 26 of them returned. “Some of these decisions come from leaders, but they need your voice to give them some of these ideas of what's happening,” Dr. Ellis said.

The culture change was not just asking questions proactively, before anyone resigned, but showing that the organization cares. “It really shows some compassion, that they care about how the workforce feels about working here and what's working for them,” Dr. Ellis said.

4. Transparency and psychological safety

In the final case, a rising third-year internal medicine resident who used they/them pronouns was asked to serve on the department of medicine's diversity, equity, and inclusion (DEI) committee as a “listening ear.” Other members of the committee included senior leadership staff.

At the inaugural meeting, the resident was introduced as the “resident representative” (whereas everyone else was introduced by their name and title) and was provided a seat in the room. “But it was off of the main conference table at the periphery of the conference room,” Dr. Sagar said.

In addition, the other committee members received an introductory briefing call on why the DEI committee was being called to action, their specific roles, and the committee's overarching goal. The resident received no such context.

After that meeting, the resident voiced concern that they might not feel comfortable serving on the committee due to lack of clarity about their responsibilities and barriers to speaking up in the presence of the other members. “They really have this feeling of disempowerment because they've been asked to be a listening ear … [and have not been] addressed by their name or their preferred personal identified pronouns, but rather as the resident representative,” Dr. Sagar said.

In this case, the elephant in the room was psychological safety, or the ability to bring forth ideas in a nonpunitive environment, she noted. “It's the ability to create an environment in which we can have a voice [and] we are given permission to brainstorm out loud, openly challenge the status quo in a respectful manner, share feedback that's transparent, and work through disagreements, because that is the only way progress will be achieved,” Dr. Sagar said.

Without transparency and psychological safety, organizations cannot make necessary changes, she said, adding that the Institute for Healthcare Improvement and Safe & Reliable Healthcare in 2017 published a framework for how organizations can create a system of safety.

Some potential solutions to the resident's concerns included finding a new room that can fit everyone around the same table, hiring a coach or psychologist to advise the chair on leading the committee, and asking everyone to share their preferred name and pronouns, Dr. Sagar said. “Our case [demonstrated] good intentions in creating a DEI committee, but there needs to be cultural change in how people are involved,” she said.