Stanford’s WellMD Center blazes a trail to promote joy in medicine, combat burnout
Physician burnout has become a topic of interest in the medical community in recent years, with the level of urgency increasing on what seems like a weekly basis.
In a recent paper, experts at Harvard and the Massachusetts Medical Society declared physician burnout a public health crisis, and institutions across the country are appointing Chief Wellness Officers to strategize and implement plans to combat this growing problem. Stanford, however, with the launch of their WellMD Center in 2017, seems ahead of the curve.
Healio Psychiatry spoke with senior advisor to the WellMD Center, Bryan Bohman, MD, about their goals, progress and how they’re helping the medical community take steps to improve the lives of their staff and therefore the well-being of their patients. – by Stacey L. Adams
Question: What led to the creation of the WellMD Center?
Answer: We started working on this almost 10 years ago, before it was quite as evident that burnout was a major problem. We saw it brewing and thought that to attack this global problem, we needed to consider physician and care team wellness as an essential aspect of the health care system. Just as hospitals have a quality department and the resources to monitor, maintain and improve quality, the same needs to be done for provider wellness.
Evidence shows that the wellness of the health care providers has important effects on the health system performance — not just in quality, but also in patient satisfaction, financial outcomes, productivity and physician turnover. We wanted to create a structure that would emulate a quality department — a sustainably funded, organizationally endorsed center that would measure wellness, explore ways to improve it and basically elevate the consciousness of everybody in the organization that this is a major issue.
Can you talk a bit about the newly created Chief Wellness Officer position?
About 5 years ago, a physician wellness taskforce commissioned by our dean recommended the creation of a wellness center. That in turn led to the concept of a Chief Wellness Officer (CWO) for the entire organization. We established the WellMD Center about 2 to 3 years ago, and Tait Shanafelt, MD, was appointed CWO about a year later, in 2017. Tait is a leading figure in physician wellness; he and his colleagues at Mayo Clinic have been major contributors to the science of physician wellness. As CWO, Tait is a presence at hospital board meetings and other high-level forums with hospital and school of medicine leadership — where he can help influence decision-making to ensure that it reflects the organization’s high priority on improving care team wellness.
Can you tell me more about the Physician Wellness Survey?
We conducted our first survey about 6 years ago, the second about 3 years ago, and this year we will begin surveying on an annual basis to better understand our status. Because we developed our own survey, led by Mickey Trockel, MD, PhD, we’re able to measure not only burnout, but also fulfillment, and also assess the drivers of both fulfillment and burnout. With colleagues across the country, we have developed a model that divides these drivers into three different areas: (1) personal resilience, (2) culture of wellness and (3) efficiency of practice.
Personal resilience of course includes people taking care of themselves physically: the basics like sleeping enough, eating well and exercising. But we’ve also learned that mindfulness is critical, and it turns out that one of the main drivers of burnout is a lack of self-compassion, or self-valuation. When you reflexively blame yourself and beat yourself up for normal human errors, you harm yourself. It’s so much better — for yourself, and for your patients, colleagues and family — to react to an error by trying to learn from it. As health care providers, we’re especially susceptible to self-flagellation, because medicine attracts highly conscientious people who are trained to hold themselves accountable for everything that happens to their patients.
Our health care systems are highly complex, and good outcomes depend on great teamwork and solid process management, but when things don’t go right, we do tend to blame ourselves. We aren’t, of course, advocating for a lack of self-assessment, but we do advocate a positive learning mindset that asks “How can I learn from this? Is there something I did wrong? How can I do better? Is it something that the system is failing on? How can I make the system better?” And we have found that that attitude is hugely protective against burnout. The opposite: “How could I be so stupid? I’m probably not good enough. I harmed my patient. It’s all my fault,” — that approach doesn’t really lead to improvement, and also puts you at higher risk for additional medical errors and for burnout.
Resilience is important and physicians should consider self-care as a professional obligation, similar to staying current with the latest medical literature. But with over 50% of physicians nationwide showing signs of burnout, health system leaders must not put the burden on the backs of physicians to simply “heal themselves.” We must take responsibility for improving health care systems, schools of medicine, and the culture of medicine so that we don’t create burnout among the highly capable and psychologically healthy individuals who enter the profession.
Which brings us to our model’s second domain, the culture of wellness, which centers around the question: Do your leaders and peers value the health and well-being of caregivers? Ten years ago, the medical culture was very different, and 20 years ago it was even worse. The notion that providers are indestructible, that they can be up all night and still provide their best care for patients, is frankly a denial of human reality. Yes, we need highly dedicated people who are willing to stay up all night when they need to, but the idea that they’re providing reliably outstanding care the next day — we’re deluding ourselves.
I believe there’s been a real evolution in attitude over the last 10 years where it is starting to feel less like a self-indulgence to take care of yourself and more like a professional obligation. A culture of support, recognition and good leadership traits is really important. This has been studied by Tait and colleagues, and they found that a lot of the differences we find between departments within a given organization, especially with regard to professional fulfilment, are related to leadership traits of the relevant leaders. Does your leader care about you? Does she demonstrate that she cares about you? Does she ask about your career aspirations? Does she show that she cares about the day-to-day life of the people in her department? That sort of thing.
Finally, the third domain that we looked at is perhaps the most important: efficiency of practice. Over the last several decades it’s been harder and harder for physicians to provide the high-touch, personal care that they want for their patients. The system has become so complicated and the demands on us are so great in terms of documentation, care coordination, etc. The ability to give the kind of care that we’ve been trained to give, and making that human connection, has been impaired. And that’s what really leads to burnout. It’s the health care system and processes failing to support clinicians adequately so that they can deliver excellent care efficiently and reliably, so that at the end of the day you can feel you’ve done a great job and you can go home and relax and not have to fret about whether you forgot to order Mr. Jone’s colonscopy, and not have to spend hours of “pajama time” finishing your notes in the electronic medical record.
We think it’s crucially important that organizations take on the challenge of improving efficiency of practice and the culture of medicine, and as part of that, we should encourage people to take care of themselves rather than looking down our noses at colleagues who may need to take a day off when they are under the weather or have a family issue to deal with.
How are you putting these ideas into practice?
At Stanford we’re building the capability to execute on those three domains. We’re building a course to help train our division chiefs on how to be better leaders because of course leaders want to take good care of their people, they just may not have ever really learned how to best do that. We are also devising ways to identify areas of inefficiency of practice — for example, by looking at physicians’ use of electronic medical records. If, say, we can identify differences in the amount of time doctors in one primary care clinic are spending on their EMR, as compared to another, perhaps we can find ways to improve efficiency in the clinic that is “stealing” extra time from its doctors. Our goal at WellMD is to work with our health system administrative colleagues to monitor drivers of burnout the same way we monitor hospital-acquired infections. If we can develop “early warning systems,” then hopefully the health system can intervene before folks end up burning out.
We’re looking at building those kinds of approaches, we’re implementing peer support, we’re supporting people in their mindfulness endeavors, we are bringing people together to talk about meaning in medicine, building a sense of community, a whole host of activities that have an impact in all three of our model’s domains. Putting all of this together, we’re confident we’re going to see things improving over time.
How are you helping other institutions and organizations in the US?
We are reaching out to work with colleagues across the nation and internationally. One example is our Chief Wellness Officer course. We hosted the first course in 2018 with about 40 participants who came for a full week of lectures and discussions so that we were all able to learn from each other. Several recent papers, including one published in Health Affairs, recommend that every organization appoint a CWO — someone who’s devoted to ensuring their organization is paying attention to burnout and bringing it to the attention of leadership, so I do think we are influencing other organizations, and we’re doing our best to support folks who are looking to become CWOs.
We also initiated a Physician Wellness Academic Consortium a couple of years ago. The consortium includes 15 to 20 academic and large health systems and they’re all administering and helping to improve the same survey tool we discussed earlier. Now we have benchmarks, so that folks can look at each other’s results and notice that one system may be performing better in, say, an element of self-compassion, and they can inquire about what that organization is doing to produce that result. These are all top-notch organizations and great people who I have no doubt will help us find effective ways to address the burnout problem and go beyond that to focus on optimizing professional fulfillment.
Other outreach efforts include an annual American Conference on Physician Health, in partnership with Mayo Clinic and the American Medical Association, and we’ve also entered an exciting partnership with the California Medical Association. They’ve contracted with our WellMD Center to lead wellness efforts for California physicians statewide. The CMA is investing millions of dollars to bring some of the programs and ideas that we’ve been talking about to physicians across the state in a variety of different ways. We believe that this work will yield results that will inspire other medical societies or health care organizations to provide similar services to their own physicians.
Can you share some final thoughts?
There’s a lot going on in this very exciting field. It often gets painted as a negative, for obvious reasons given the level of burnout. We are where we are, people are very stressed in general — and it’s a very stressful profession right now. We’re stressed for some good reasons, though. Health care is way too expensive, our reliability and our safety are not where they need to be. We provide unnecessary care more than we should, we fail to provide needed care as reliably as we should. As an industry, we haven’t built systems and processes equal to the complexity and importance of the care we deliver. And so yes, we are seeing a toll on our people: doctors, nurses, all members of our care teams.
But there is definitely reason for optimism. I strongly believe that the combination of focusing on wellness as a high priority and developing performance improvement capabilities in the industry is going to be what pulls us out of this spiral we’ve been caught in of late. Those two activities are vitally linked: we cannot “solve” burnout without doing performance improvement, and engagement in performance improvement is itself an important element of professional satisfaction because it helps us feel that we can actually exert some positive control over our practice environments.
If you look at the bottom line of what makes physicians happy, it’s being able to take great care of their patients. That’s why we went into medicine, that’s the way we were trained, and so we will absolutely beat ourselves up trying to do that. If the system doesn’t support us being able to do that in a way that’s compatible with normal work-life balance and stress levels, we will keep trying anyway. That’s the nature of the beast. Your patient is right there in front of you, there’s no industry where the motivation to do your best work is as great as it is in medicine, so we will burn ourselves out. What we’ve got to do is create a system where that’s not necessary, where we can take good care of our patients without burning ourselves out. When all the dust clears, that’s really what it’s all about — fixing the system of health care. But who’s going to fix it? Not the “walking wounded” who are burned out but rather those who, for whatever reason, remain professionally fulfilled and ready to lead the transformation of medical care.
It’s a vicious cycle: The more burned out people are, the less likely they are to engage in improvement efforts, and the less likely they are to take care of themselves, so they get more burned out. We must find ways to break that cycle — to create a virtuous rather than a vicious cycle. A virtuous cycle is one where you feel a little better about yourself, you then make an effort to improve your own system of care, whether it’s your individual practice, your whole clinic, your whole health system, or at the national level. We need to work on all levels, and as we start to make progress it’s going to energize us and feed on itself. I think we’re starting to see the effect of that already — people are getting excited about this and are starting to put a lot of effort into solutions. We will see progress, success will beget success, and the future will be brighter. I’ve been called “Polyanna” by some, but I strongly believe that the evidence justifies my optimism.
Disclosure: Bohman reports no relevant financial disclosures.