Training and Leading Physicians for the Fight Against Moral Injury

Note: This is part two of an ongoing blog series on burnout vs. moral injury. In the first installment, we learned that almost no one wins in our current system. Here, we will discuss how the Quadruple Aim is the most effective in achieving a more efficient and sustainable solution.

It is pretty clear we have an injurious healthcare system that overburdens healthcare professionals and under-provides for too many patients. The Triple Aim, Introduced in 2008 as a means to improve patient care, while commendable, fails to account for important players in the healthcare system. It is hard to argue that improved outcomes, better patient experience, and lower costs are important goals. If we were to achieve them our healthcare system would make vast improvements. The problem with the The Triple Aim is it doesn’t adequately address the full scope of the problem. In this article, we argue the Quadruple Aim is a better model for improving healthcare, and we offer three steps leaders can take in the fight against moral injury and burnout.

Post-Fight Analysis - Who Is The Real Opponent

In Part 1 the decision was unanimous - there is no winner in the fight arguing over the terms moral injury versus burnout. Instead, the fight should be against moral injury. The opponent IS burnout. With that in mind, how do we move forward? I strongly believe the path forward is to allow physicians to continue to fulfill their mission to provide high quality care (improve patient outcomes), to provide personal care (improve patient experience), and to encourage self-care, well-being, and anything that will enhance the healthcare professional’s experience or satisfaction. The fighter must be and stay healthy. If we are not healthy, how can we deliver the best care? If we are to encourage health for our patients, what if we actually modelled it?!

Once again, I commend the authors for advancing the discussion. The first key is to raise awareness and understanding.

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Training Physicians for the Future Fights

The second key to achieving the Quadruple Aim is training. How do we train and empower our physicians for future fights? Training physicians should be ongoing, rather than just at the beginning of a career. Training needs to include the awareness and understanding of burnout and the effects of moral injury. Training must include management as well as prevention of burnout. How should we allow rest and recovery in our “fighting” career? How does one dodge the punches, avoid the many cuts, and at worst, the knock-out blow?

In my opinion, training should include burnout prevention, self-care, wellness, and positive resilience training. Our existing training focuses way too much on negative resilience training techniques! Burnout is not a failure of resourcefulness or resilience. Burnout is the result of our resourcefulness and resilience at the expense of our own well-being and satisfaction.

The way to achieve wellness and healthcare professional satisfaction is to PRACTICE it.

Who are Our Coaches, Managers and Leaders?

The third key is that our leaders must embrace healthcare professional wellness and satisfaction. I agree with the authors that simple wellness programs and wellness officers will not solve the problem. I do know from my experience that mindfulness, positive resilience training, and forms of cognitive behavioral therapy are proven wellness strategies. The fighter will benefit by practicing many of these techniques that were not part of traditional medical training.

However, we need outstanding coaches, managers, and leaders who understand that physicians are not weak and do not lack resilience. We will see the greatest impact on wellness and burnout prevention when our leaders understand what causes moral injury and take steps to avoid the counterproductive actions that burden physicians. Establishing wellness programs and training wellness officers / leaders will be an investment of time, energy, and money to be effective. We must train wellness officers who are strong health professional advocates and enlist wellness programs that challenge old ideas.

It is time for our leaders to embrace the fourth aim and start championing physician well-being and satisfaction. If we do, we can reverse the current trends and fight moral injury and burnout.

If we do, patients, health professionals, and the healthcare system will win.

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Hospital Characteristics that can lead to Doctor Burnout

In an article published on titled “Is your hospital a miserable place to work? Here are 14 clues,” Dr. Robert Khoo sarcastically offers 14 guidelines for hospitals to follow in order to make their employees more miserable and prone to burnout. Dr. Khoo details these guidelines to prove a point about hospital work conditions, and I’m sure many surgeons can personally identify with many of these. This article was written in 2015 but these issues are still prevalent in many hospital settings. In this article, I’d like to take a look at 8 of these 14 characteristics and how they can lead to a burnout-prone work environment.

Top-Down Management

When upper managers make blanket decisions without considering or addressing the needs of specific participants in different departments, it can be incredibly frustrating. Involving us in these decisions is a great way to ensure happy surgeons across the board.

Doctor’s Lounge

The doctor’s lounge has been making a comeback recently in some hospitals in the broad effort to combat physician burnout. Doctor’s lounges can offer a place for doctors to find a quick mental, emotional or physical recharge amidst what can be a very hectic and stressful work environment.

Quarterly Staff Meetings

It’s essential to field questions and take feedback from physicians during quarterly staff meetings rather than using this time to simply explain new procedures and protocol.

Dealing with Burnout Complaints

Take complaints of burnout from physicians and other staff seriously, as it correlates with patient quality and efficiency outcomes. Burnout is a serious issue and should be treated as such. Even better, take steps to help decrease stressors, offer opportunities for choices, or allow some control to be felt by those working with your system.

Irrelevant Metrics

Focusing on irrelevant metrics will only frustrate and anger your surgeons. Patient care is more difficult to quantify, but is the most important metric. Understand that at our core we are driven more by quality than quantity.

Patient Reviews

Patient reviews are important, but not nearly as important as great care. If a surgeon gets a poor review because they refused to overprescribe for a patient, don’t make them feel under-valued. Consider modifying mission statements and educating patients and family members that their satisfaction is a high priority, but not at the expense of their care and well-being.

Cutting Expenses

Cutting expenses while demanding increased productivity or compliance with additional administrative burdens of the human elements, while cutting expense in areas of support is a recipe for burnout or failure. Look for technical or system efficiencies that help save money. Educate surgeons and staff on process improvement strategies that save time and money.

Work / Life Balance

Many physicians and surgeons work crazy hours that cut into their family and home time. Encourage a healthy work / life balance that allows professionals to promote patient wellness by example or role-modeling surgeon wellness.

Addressing These Issues

These 8 characteristics of burnout-prone hospital environments are a serious concern to surgeon wellness. Let’s make an effort to work with our hospital’s leadership to address these issues if present, and provide the best work environment for patient care.  If you have tried this on your own and failed, don’t give up. We can do this TOGETHER! Let us know how we can help.

Longer First-Year Resident Shifts May Equal More Burnout

The Accreditation Council for Graduate Medical Education (ACGME) announced that medical residency programs can begin increasing shift hours for first-year residents starting in July 2017. While this new policy is aimed at improving outcomes for both patients and residents, it has many critics who claim that it may lead to increased burnout. I am agnostic on the hours, but I am passionate about burnout prevention.

Shift Increases

Currently, shift hours for first-year residents are capped at 16 per shift. In July, that number of maximum shift hours will increase to 24 (with an additional four hours devoted to taking care of patient hand-offs). Despite this change, 80 hours is still the maximum weekly amount for first-year residents. 

The change is aimed at improving all of the following:

  • Patient Care Continuity
  • Clinical Teamwork
  • Resident Learning Experience

Using The 8 PRACTICEs of Highly Successful Surgeons, we should start with a Passion for Performance Improvement. 

Critics of the New Policy

The new shift policy has its fair share of critics – among them the American Medical Student Association. These critics contend that increased hours will lead to increased stress, burnout, sleep deprivation, and mistakes. I am not saying it is good, but reality is that sleep deprivation, stress and mistakes are a part of medicine. Our shared goal is to minimize all three and maximize care continuity, teamwork and resident learning experience.

Sure, total weekly hours are still capped at 80, but that doesn’t mean that residents are using that time for rest and effective stress reduction. There are also many stories of the pressures placed on residents to bend or break the rules. 

Can we all agree that the human body, mind and soul needs time to rest and recharge? 

If we all aim for improvement, mistakes are less likely to occur, and we will also improve patient care continuity, clinical teamwork and resident learning experience.

The 8 PRACTICEs of Highly Successful Surgeons

I have struggled first-hand with burnout in my time as a medical student, through residency, and in private practice. Through these experiences I have developed my own signature methodology for preventing burnout. I call it the 8 PRACTICEs of Highly Successful Surgeons. This system is designed to help all physicians across all specialties prevent burnout by encouraging healthy habits, and finding your own rhythm. Drop me a line today to learn more about the 8 PRACTICEs and prevent burnout before it strikes.

4 Ways to Conquer Surgeon Burnout

There are many factors that can contribute to burnout among surgeons, doctors, and other medical professionals. It is not all about diet, exercise and sleep, but these three are basic foundations that increase our ability to go after the other factors. This article will offer four tips for conquering surgeon burnout and its related symptoms.

Try to Practice What You Preach

If you notice, many of my articles point out the simple practices of diet, sleep and exercise. I am not a perfect example, nor is anyone for that matter! If we are going to restore our passion and strive for performance improvement, we need to abandon perfectionism, and just get better. I have made tremendous progress in diet and exercise by using baby steps. I preach performance improvement, not perfection. How can you do better at something you tell others to do?

Set Realistic Goals

Each successful achievement makes it much easier to reach the next. There is little harm in overachieving on a goal that was a little too easy to reach. However, when we fail to reach a goal, usually one of two negative things results:

  1. Our motivation to reach the next goal is decreased.

  2. We make excuses that justify the failure, therefore making it easier to justify a failure each time.

Create momentum with success, by reaching your goal and maintaining it.

Say No

Surgeons tend to overexert themselves at work. If only we could do everything we wanted! Unfortunately, that’s just not the way we’re built. Saying yes to everything at work will likely lead to excess stress, exhaustion, and burnout. Know when and how to say no at work and you will become much more successful.

Diet, Exercise and Sleep

We’ve talked about these three factors at length, and they are important to understand. If any of these three are managed poorly, the results are lower energy levels and higher stress. Use each of the first 3 ways above to attack all three issues.

All of these tips tie into my burnout prevention methodology - The 8 PRACTICEs of Highly Successful Surgeons. I developed this system after dealing with burnout first hand in my own practice. It can be applied to any physician in any specialty. Focusing on finding your rhythm in your work and home life is the ultimate goal to conquering burnout in the long run.

Tips for Medical Students to Prevent Burnout

Med Student Burnout

Physician burnout is a serious issue in the United States. When discussing burnout, most people focus on doctors and surgeons, completely ignoring another group that is just as prone to burnout – medical students. Feeling burned out can lead to a drop in academic performance and more. Medical school is intense. Been there, done that. Don’t envy you. But I can try to make it a little less stressful. This article will focus on med student burnout – with a few tips for burnout prevention.

Learn How & When to Say “No"

Obviously you can’t say no to a test or assignment, but extra-curricular activities are a different matter. Don’t overload yourself with too many extra-curriculars. When this happens, it will either cut into your academic performance or your equally important need for some time to relax and recharge. Focus on your studies, and balance the rest by saying no to things that don’t provide health and wellness.

Exercise & Healthy Eating

When you’re pulling all-nighters to study and spending hours in labs, it can be hard to find the time to eat well and exercise. But healthy eating and regular exercise are two incredibly important factors to preventing exhaustion and burnout. Do your best to limit junk food, and carve out some time for yourself to workout – even if it’s only for an AVERAGE of a half hour each day. I find it very helpful to have access to healthy snacks or healthy “fast” food options.

Practice Good Study Habits

Don’t push off assignments or studying until the last minute. That will only lead to additional stress. Get started on assignments as soon as possible after they’re assigned. Getting a jump start allows you to spread out the study time and review the more difficult concepts prior to exams. The lower stress will allow you the sense of accomplishment, and even time for some of the extras. One way to do this is to set aside 2-3 hours within 2 days of the initial assignment. Based upon that initial progress, you can more accurately predict how to spread out the work until the due date.

The 8 PRACTICEs of Highly Successful Surgeons

I have over two decades of experience as a practicing orthopaedic trauma surgeon. Over the course of my career, I’ve achieved my goals of becoming a doctor and surgeon through hard work and focus! However, I have dealt with burnout first-hand and seen the damage it can do to great doctors. Through my experiences with burnout, I have developed a methodology called The 8 PRACTICEs of Highly Successful Surgeons. This strategic methodology was developed by a surgeon for surgeons. However, many of the tenants are easily applied to medical students as well, and one “secret” that I am glad to share is that these 8 PRACTICEs started in training have even greater benefits long-term.