Physician Burnout & Care in a Crisis

Podcast Transcript

Alex Rae-Grant, MD:  Neuro Pathways, the Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology, psychiatry, neuro surgery and neuro rehab.

Neurologists suffer a higher rate of burnout and career dissatisfaction than any other medical specialist. In total, 6 out of 10 neurologists reported at least one symptom of burnout, potentially compromising their own wellbeing, patient care, and the physician workforce. Additionally, with the COVID-19 pandemic medicine is at a crisis point.

In today's episode of Neuro Pathways, we're talking about physician burnout and care in a crisis. I'm your host, Alex Rae-Grant neurologist in Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological practice, I'm very pleased to have Dr. Amy Sullivan join us for today's conversation. Dr. Sullivan is a clinical health psychologist at the Mellen Center for MS and director of engagement and wellbeing in Cleveland Clinic's Neurological Institute. Amy, welcome to Neuro Pathways.

Amy Sullivan, PsyD, ABPP:  Alex, it's so good to talk to you. Thanks for having me on today.

Alex Rae-Grant, MD:  So, let's start off with a bit about you, Amy. Tell us where you're from, and where you trained, and when you began your career at the Cleveland Clinic?

Amy Sullivan, PsyD, ABPP:  Well, that's a great question because I don't really know where I'm from. I'm from all over the Eastern side of the United States. I would say I'm from Southern Ohio, but have kind of been all over the place. Trained in Atlanta and in New York. And then, I came up to the Cleveland Clinic for my fellowship, and then went to the VA for a couple of years, which was a lovely experience. And then, came back to that Mellen Center about 10 years ago. So, I've been on staff at the Mellen Center for about 10 years.

Alex Rae-Grant, MD:  So, today we're going to be talking about physician burnout and care, particularly in the middle of a major crisis. As a thought leader in this trending topic, can you define burnout for us and tell us why it's so prevalent in the healthcare field?

Amy Sullivan, PsyD, ABPP:  I think burnout is a very complex thing to define. So, when I think about burnout, I think about a couple of different things. First, we know just the term itself was only coined back in the 1970s, so it hasn't been too long that this terminology has been around. And what burnout is, is it's used to describe the consequences of severe stress relative to high ideals. And so, the definitions of burnout include things like a low sense of personal accomplishment, disinterest in empathetic care and communication with patients, loss of meaning or values, and all of which can lead to distress and depression, which is very concerning from my perspective.

When we look at the ICD-10 definition, it states that it's a state of vital exhaustion. And what is so important for us to understand is the prevalence of burnout in the medical profession. So, specific to neurology, because we're talking on a neurologist podcast, we know that about 42% of neurologists report some sort of burnout. And a statistic that's pretty sobering for me is that it's two times as likely in females as it is in males. So, just a little bit of background information on what burnout is.

And then, your second question was why it's so prevalent in healthcare. And the way that I think about this is that when we think about healthcare workers, healthcare workers are typically in this field because we, you, our colleagues are caregivers by nature, we are perfectionistic. We tend to be type A, we have an incredibly high work ethic, very dedicated to our careers, very, very value oriented. And all of this and the inability to really put down our work, we're constantly thinking about our patients, we're thinking about something that we can do to make their lives better, it's really the perfect storm for burnout.

And so, I think about, Alex, I've been so fortunate to have you right next door to me over the past 10 years. And you and I have had so many conversations about burnout and, in particular, how it affects our neurology colleagues. And I just think that it's really important that we're discussing this today. So, I just want to thank you for giving the time and attention to this conversation today.

Alex Rae-Grant, MD:  And to you too, for taking a lead in this whole field, it's a really important one.

So, we know that physician burnout was becoming a major issue. Then, of course, this pandemic comes into it, and even people who are not on the front line of healthcare, I think, are feeling the heat. So, can you tell us some concerns that have come to light during the pandemic, and how is it affecting healthcare professionals today?

Amy Sullivan, PsyD, ABPP:  Yeah, I think about this often in terms of how we can protect our own caregivers, as well as our own patients, because I think everybody's kind of dealing with a new crisis. And one of the things that I think this is due to is the uncertainty of the virus. And so, this really impacts how we think about the world, to how safe we feel going into the world, how safe our patients feel coming to see us, or even using virtual platforms to see us.

And that brings me to my second point, which is this transition of virtual care. And so, prior to the COVID pandemic, I know in my practice, we were using virtual care at about a 5% ratio to in-person care. And within a one week span, we transitioned 100% to virtual care. When I think about that, we had to make decisions that were for the best care of our patients, making sure our patients are well taken care of, but this was prior to guidelines or regulations being set forth. And so, this could cause a lot of anxiety to our caregivers, our healthcare workers, to people who ... we're rule followers by nature. And so, we don't want to compromise our licenses or jurisdictions.

Another reason is loneliness. And so, I think about the Neurological Institute in general and the nature of the NI is that we're sent into these centers. And in these centers, we've developed very good friendships over the years, and we're used to seeing people. And, Alex, I know you and I have talked about this over the years, I'm used to you popping in my office and just checking in and seeing how I'm doing. And same with some of our other colleagues. And we don't have that anymore. So, we're not seeing our colleagues, who are our friends.

And then, our patients are very important to us too. So I don't know about you, but I've noticed that not seeing my patients, I'm "seeing" them virtually, but I'm not physically in the same room with them. And they're very important to me too. And so, I'm really missing seeing my patients.

And then, finally, I think that when all of this comes together the stress of just being at home, in some instances, may be tough for many people. So, people who have young children, or people who have even school-aged children that have limited camps, or things for their kids to do this summer, and were responsible, really, for childcare. And then, if you're caregiving for, maybe, an elderly patient, or a disabled elderly parent, I should say, or maybe a disabled partner, or a family member the stress of caregiving is right there. So, I think there are a lot of reasons why people are feeling more burnt out right now.

Alex Rae-Grant, MD:  Wow. I think we're all experiencing those and some more than others. And I do feel bad for parents of kids who are having to be teachers, and coaches, and do all the other activities. It's a pretty tough, you hear the line about a kid saying to their mother or father, "Hey, do I have to have the same teacher next year?"

Amy Sullivan, PsyD, ABPP:  And we don't know the answer yet.

Alex Rae-Grant, MD:  We don't know the answer.

So, let's change gears a little bit. We know that healthcare workers, just like the rest of the population, sometimes have preexisting mental health conditions that they deal with. Does that factor into people getting burnout, and having problems during this time of crisis?

Amy Sullivan, PsyD, ABPP:  Yeah, that's a great question. So, one of the things that we know about mental health conditions is that they're lifelong, they're chronic conditions. And so, they need to be managed over time. This is no different than, say, blood pressure, or diabetes, or a thyroid condition. These are all chronic conditions that need to be managed over time. And so, just like in the instance of high blood pressure or diabetes, if you change your lifestyle, so in the instance of high blood pressure, diabetes, you eat more fatty foods, or you're not exercising as much, or you're not practicing wellness, your condition can be impacted. And that's the same with mental health conditions.

So, if we have people who have managed depression, or managed anxiety over the course of their life and their environment changes, so COVID hits and there's a lot of uncertainty or loneliness, or maybe they're not practicing wellbeing or wellness. So when we think about wellness, we think about proper nutrition, we think about movement or exercise, we think about managing stress. We think about spirituality, and we think about sleep. So, if one of those goes askew, and there's some certainty, and fear, whatever the emotion is, then they're more likely to have their mental health condition come back. And so, I think that it's important that we look at mental health as a chronic disease that's managed over the lifespan. And we know that when stressful situations occur, we have to be aware that one's symptoms may return.

Alex Rae-Grant, MD:  So, again, we'll change a little bit on the conversation. I've heard you speak on the topic of resiliency before. Can you briefly describe this to the audience? And what would you suggest for healthcare workers, like myself, to build resiliency to combat burnout?

Amy Sullivan, PsyD, ABPP:  So resiliency, as you know, is one of my favorite topics to talk about. So, for those who aren't aware of what resiliency is, it's really just the capacity to recover from very difficult situations. It's how one copes in crisis, it's how one returns to kind of a pre-crisis state. And resiliency develops over time. And it's really something that, in my practice, I teach patients how do we build resiliency, which leads to your next question of thoughts for improving resiliency.

And so, the first thing that I think of is an overall stress management. So, when we think about stress management, some of the things that we teach in our practice that are really simple to bring into the everyday life are things like diaphragmatic breathing, visualization, body scanning. And another part of stress management is called mindfulness. And mindfulness is probably one of my favorite skills to teach. So, mindfulness is a stress management technique that's a skill that's based in Eastern culture. And the goal is really to stay in the present moment. To not look ahead to the future where there could be anxiety, fear, uncertainty. And to not look into the past where we could see regret, remorse. And you can understand how important it is then to stay in the present moment, which is where we are right now, so that's another skill.

Another skill that I like to teach is the skill of gratitude. So, both internally and externally. So, internally meaning what do you have that you're thankful for? So, kind of reframing your thoughts, kind of the tenants of cognitive behavioral therapy. And then, externally, so how can we thank others who are a part of our lives, or maybe just somebody who's doing something that contributes to our life, and how can we thank them for what they've done. And there are many studies that show you that if you participate in gratitude, and thanking other people that both the sender of the gratitude, and the receiver of the gratitude have positive outcomes from that.

And so, another suggestion that I have is to connect with others. And so, like we had said earlier, right now is a very difficult time in our culture, and in our world because we're not able to connect as we once did. And so, we have to become creative in terms of how we're connecting with others in a safe environment. And then, finally, just having that general wellness approach to something that we talk about regularly at Mellen Center, which is movement, nutrition, sleep, spirituality, and stress management.

Alex Rae-Grant, MD:  These are probably all things that we can think of not just during a pandemic, but at any time, obviously.

Amy Sullivan, PsyD, ABPP:  Yeah, absolutely.

Alex Rae-Grant, MD:  I know you've been very actively working on the burnout issue in our institution, well before COVID-19. Can you share with the listeners how your cross functional team approach can address this concern?

Amy Sullivan, PsyD, ABPP:  So, I've been in my role for about three and a half years. And really from my relationship with Dr. Machado, he's just given me kind of free rein to think, and to try to develop this program, and to best serve the NI. But, also, to serve outside of the NI, and those that are in different institutes where we're working with other wellness and engagement champions. So, one of the things that we started with really was just taking a deep dive into the Press Ganey, and into our pulse survey to see what the concerns of our caregivers are. And they range across the board, but it's really important for us to hear what our colleagues are saying and see if there are solutions to that.

So, from there, we have held over the course, now, of three and a half years, multiple town halls. And in these town halls, the idea is to openly address the concerns, and to allow a space for process and solution oriented thinking. And so, we've gotten a lot of great ideas from people throughout the institute about how we can improve the Neurological Institute.

Dr. Machado, and I hold monthly engagement dinners ... well, not currently, but we have over the course of the past three years. We hold a monthly engagement dinners with our physician staff. And this is a place where we work on connections. So, in the Neurological Institute, we tend to be kind of siloed into our own centers. And this is a place where we bring people together from all different centers and departments within the Neurological Institute. We sit around a table, we talk, we connect. Collaborations are made there, we process, and we come up with solutions to what may be some difficult issues to bring up.

And then, currently, our most recent initiative is starting to look at flexible scheduling in hopes that it will ... One of the reasons why we see in the literature that people are burnt out is because they feel like they don't have flexibility in their schedule, they lack autonomy. And so, our goal really with this flexible scheduling program is to improve a person's autonomy and flexibility, and therefore work satisfaction. And then, to decrease burnout. And, with that idea, we also have IRB approval for a randomized control study, which the two arms will be flexible scheduling versus standard scheduling. And then, really our goal is to look at the effectiveness of flexible scheduling on burnout, as well as the effects of digital care on burnout. So, we're very excited to see what we're able to find, and to see if this helps to improve physician and caregiver burnout.

Alex Rae-Grant, MD:  Well, good luck with that key research.

Amy Sullivan, PsyD, ABPP:  Thank you.

Alex Rae-Grant, MD:  So lastly, before we finish, what kind of key takeaways would you like to provide to a healthcare workers who, themselves, may be suffering from burnout, or are concerned about a struggling colleague? What do you think they should take away from today's conversation?

Amy Sullivan, PsyD, ABPP:  So, I would just like to say that high stress times traditionally correlate with burnout, and we've never seen a time like this before in our lives. And so, I think it's important to have patience with the time. It's important to normalize the ebbs and flows of our emotions. And so, we also need to be looking at burnout, and knowing that this can quickly progress to something dangerous, like depression or even, in some cases, suicidal ideation, or suicide. We also know that burnout significantly impacts patient care. And so, being in the Cleveland Clinic and the Neurological Institute our standard of care is extremely high, and it should be. And so, we want to make sure that our patients are well taken care of, therefore we have to correct burnout. It also impacts relationships with family and friends, and it impacts best practice in medicine. And so, all things that are incredibly important in terms of taking care of our patients and taking care of ourselves.

I also want to just remind people that because healthcare providers are typically very empathetic and perfectionistic, and hardworking it's difficult for us to separate work from our home life, because this is a calling for many of us. And we think constantly about our patients, and how to improve their quality of life. All of this is really the perfect storm for burnout. And that there are solutions and ways to cope. And so, I think it's important that one knows that it's okay to reach out for help. It's okay to ask people to help in your clinic, or to receive mental health care if you need it. But, mostly, just to know that there are ways to improve burnout. And if there are thoughts or suggestions, please feel free to let me know, so that we can implement those because we are listening.

Alex Rae-Grant, MD:  Well, Amy, it's an extremely demanding time for providers and healthcare workers, and your insights are really helpful to people. I thank you for taking the time to share your thoughts on this important topic today.

Amy Sullivan, PsyD, ABPP:  Thanks so much, Alex.

Alex Rae-Grant, MD:  This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute, on our Consult QD website, that's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @cleclinicmd, all one word that's at C-L-E clinic M-D on Twitter. Thank you for listening. Please join us again soon.