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Burnout and Wellbeing in Healthcare, Dr. Kernan Manion
Burnout and Wellbeing in Healthcare, Dr. Kernan Manion

Kernan Manion
Kernan Manion, MD is the director of Work/Life Design, a novel coaching and consultancy service devoted exclusively to assisting individuals and organizations in identifying and resolving the matrix of issues which contribute to disabling occupational stress, compassion fatigue and burnout, and to helping to craft pathways toward enduring individual and organizational well-being.

Dr. Manion attended LSU Medical School in New Orleans and trained in Adult Psychiatry at Tufts New England Medical Center after completing an internal medicine internship and a subsequent interim year of emergency medicine practice. He has been in practice in Massachusetts since 1983 and has served on a rich diversity of hospital and clinic medical staffs. He took a particularly avid interest in understanding and addressing professional burnout in 1995 upon recognizing its emergence both in the lives of colleagues as well as in his own.

He became familiar with quality systems paradigms as they apply to healthcare and was invited to become an examiner for the Massachusetts Quality Award (which follows the Malcolm Baldridge Award criteria). He began to apply various creative problem-solving tools to his work with physicians grappling with occupational stress. He had the fortunate opportunity to receive training at the Harvard School of Public Health Program in Health Care Negotiation and Conflict Resolution and is pleased to serve as head of its alumni association. He has incorporated many of the program's effective communication and conflict resolution strategies into the Work/Life Design approach.

Work/Life Design's approach follows a collaborative solutions-oriented coaching model whose immediate goal is to help all professionals providing human services - within healthcare and out - fully explore the unique contributors to their worklife stress and craft optimal change scenarios which enable both individual and organizational well-being.

Work/Life Design is ultimately about helping the helpers - those who are faced with the awesome responsibility of providing the vital human services of healing and caring to others - to restore well-being within their work.

Dr. Manion is pleased to have the opportunity to facilitate this HealthBond forum and looks forward to enabling active discussion on these issues and responding to issues of concern that members of the HealthBond community might raise.

Work / Life Design
Helping You Achieve Wellbeing Through Personal, Career and Organizational Health
"Collaboratively Crafting Transformational Change"
Kernan Manion, MD Director
1620 Sudbury Road, #5 Concord, MA 01742
978-369-0368
kmanion@pol.net


Question 1 - This is a topic we over look in the healthcare industry. One that all organizations should take into account especially with the climate as it is today.

Last year ACHE communicated that the CEO turnover rate is higher than it has been in 10 yrs. A few weeks ago the ACHE published that is it lower than it has been in some time. Claiming that it was due to better positions. My experience thus far tells me it is due to a difficult environment with little vision and needs a new kind of leadership than we have had in the past.

What has been your experience when working with healthcare leaders? What are you seeing in the industry? other professions? What are the key elements you prescribe for reaching self actualization in ones job in this very confusing healthcare industry? by Luke on February 28, 2000

Answer 1 - Hi Luke, Thank you for your question and thoughts.

At first, I wanted to offer a witty response to the reported ACHE findings - it's no surprise there's less turnover - there's nothing left to turn over! It's like an army general proudly saying "we have much less turnover" - not mentioning that half the troops are dead, there are no new recruits, and the ones who remain are so busy fighting for their lives they don't see a way out of the battle!

I think it'd be more valuable to actually ask people "what's the quality of your life as a healthcare exec? Are you finding any joy in it? Or is it just relentless battle, dodging landmines and bullets? Do you foresee any let up? How are you personally coping? And how are you helping your organization, that diverse group of talented and caring people under your stewardship, cope with it?"

I share your observation about the lack of vision. My sense is that we have not created the opportunity for all of us to come together and ENVISION. To envision what an optimal healthcare system would look like. My training in Conflict Resolution and in systems tools tells me that, for there to be a workable solution to the healthcare crisis, there's going to have to be the opportunity for ENVISIONING and collaborative problem solving. And there preliminarily needs to be a convocation and consensus around mutual problem definition. A crucial step in the analysis of turmoil (and I think it's fair to say we have turmoil in healthcare today) is to name and understand the diverse range and confluence of issues involved. I haven't seen that done in any systematic way yet. True, it's hard to "envision" when you're in battle - not much great poetry is written from the trenches (and if so, it's usually 'last words'). But we must be coming together both to share the conundrum and to envision.

How do we do that? Some preliminary thoughts - "communicate, communicate, communicate" - we have to create the forums for dialog and creative problem solving. And there are remarkable methodologies out there to do that! Open Space, Future Search, various styles of interactive workshops for people in healthcare, focus groups. But it's about DIALOG, not just "talking head" conferences. WE in healthcare - not consultants, not "experts", not government - WE are uniquely positioned to have the dialog, to explore the issues and to arrive at the answers. If any significant participants are left out of that dialog - patients, providers, institutions, payers, employers, suppliers, other stakeholders - then their needs and cogent observations will not have been heard and the "solution" derived will not work - because it does not account for their needs.

Like nature abhorring a vacuum, systems abhor chaos. And if the system doesn't right itself, an external force usually opportunistically intervenes to "restore order". We have the tools and the intelligence to envision and create. It would be most unfortunate to let this crisis, this opportunity, fall by default, into the hands of a "mandated" solution. (Alas, that's what appears to be happening - when things get to the "by law" stage, it's become a mandated solution. Is congress the only place where we can hammer out collaborative problem solving? I feel that, just as mediation is a form of "collaborative law", so too we need to find a systems equivalent for collaborative solutions - not just our current legislative default mechanism of crafting an interest-group influenced law through congress.)

With regard to other industries - yes, it's happening in many other industries. There's a turmoil, a sense of great unsettlement, of leadership lost in a fog, of having lost the thread of the mission and vision, disconnected from management who are disconnected from their workers. The teaching profession - especially the grammar and high school levels - are in turmoil; there is a crisis of spirit in the pastoral fields - priests, ministers and rabbis; and in law, where even those with lofty ideals are caught in a consumer "mercenary" mentality. Many are grappling with finding coherence and living their values in their worklives.

And to the last part of your question - can, and how do we, self-actualize, to use Maslow's term describing that peak state of being. As you may recall from Maslow's pyramid, his hierarchy of needs, that you don't get to self-actualization without addressing the other needs - survival, sustenance, connectivity et al. And where we are right now in healthcare is simply identifying and addressing the other needs. I would argue that it's actually THROUGH the crucible of addressing these other needs, of grappling with the complexity, that we actually approach that self-actualization. Are we creating environments in healthcare which ensure survival of those within? Which enable connection and community? Which foster trust, safety? Which engender creativity? We must do these in order to achieve that self-actualization, that state of well-being.

Imagine a scenario that we so often see - someone, perhaps ourselves, saying "I want good health". "Good health" requires some basic contributions on our parts - decent nutrition, healthful exercise, adequate rest, and balanced living, amongst others. You can't have it without these. Clamor all you want. You still have to do your part.

And likewise for well-being in our professional and organizational, and in our personal, lives. To restore, or achieve, or aspire towards well-being, is going to require some active participation on our part. And that's actually wonderful, isn't it? It's just as it should be. We will come together, or, we won't. We will achieve well-being, or, we won't. It's entirely up to us.

Thanks again for your thoughtful question.

Kernan Manion, MD
Work/Life Design
Concord, MA
by Kernan Manion on February 28, 2000
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Question 2 - Hello Kernan, I appreciate your comments to Luke's question. However, as I read them, it's all very conceptual, "pie in the sky" type stuff. While I enjoy these discussions I am trying to apply it to actual use. For the manager in a healthcare organization, what type of tools are out there to assess the level of staff burnout and help staff work through the burnout to acheive some level of professional "well being"? I think burnout in healthcare is considered by some to be a given (our burden to bear so to speak) and may not realize there are alternatives.

Also, I find that some staff like the martyr role and always seem to be in crisis. Is your experience that this is more prevalent in healthcare? Or does it just seem that way... by yvette on February 29, 2000

Answer 2 - Your question raises a number of provocative issues. I'll address occupational stress and organizational dysfunction in a moment, but at the outset, I'm compelled to respond to the "pie-in-the-sky" reference.

The implication often behind that phrase is that something is "unobtainable", or perhaps "unrealistic".

Worklife health - or occupational "engagement" - or "peak flow state" - may be a sublime star to shoot for. But we do in fact need to have the vision of something to shoot for; we do need a reference point both to see our objective and to realize that it is obtainable and that some others may, in fact, be further along toward that optimal state than we are.

Your question also raises a crucially fundamental issue about organizational "health". Let's be very pragmatic - non-"pie-in-the-sky" oriented. Let's dismiss "burnout" for a moment.

If an organization is operating "sub-optimally" - "sub-par", can you know it? How? And what do you do about it?

Organizations are as varied as families - different "environments", different styles, different ways of living their mission and values (even different ways of living in the absence of them!). There is no "one right way" to be a family (despite what some of the Republicans might think.)

Apart from this wonderful variability, however, there are also dysfunctional families (from which, incidentally, the larger majority of us emanate!). And when you see enough families as a consultant for comparison, you know dysfunction when you see it. Ironically, the dysfunctional family may be BLIND to its dysfunction! Why? Because this is the only family they know, the only way of being they know as a family!

Now, likewise for organizations! They have richly diverse styles, environments, and ways of living their mission and values. And, thankfully, there is no one right way to be an organization.

I've certainly been in varied organizational environments - some worked very well with the creation of a certain elan, honesty from the CEO/leadership team etc.; others didn't - either they exuded a prison like atmosphere, or a General Patton-like barracks or a snake-pit - something - but they didn't work well - (i.e. for me; some people do well in toxic environments).

Now, just as there are dysfunctional families, there are dysfunctional organizations. How does one recognize them?
Here are a few indicators:
- increased turnover
- increased absenteeism
- increased disability claims
- decreased morale
- increased conflict (even to the point of sabotage of the organization's objectives!)
- pervasive cynicism / anger / embitteredness

Why does one need to recognize this dysfunction? Can't an organization just stay that way and get its work done?

Well, sure, sort of. Much the same way that dysfunctional families eke out a "sustainable" existence. But not only is the quality of life of the family impaired, the needs of some or many of the individuals are not being addressed - e.g. safety, respect, support, guidance, installation of core values, to name a few.

So when an organization gets dysfunctional, it too is not meeting the needs of its "family"; and if these needs are not being met, then a) the various individuals don't do top quality work; and b) the customer is usually, shall we say, less than delighted.

(Now, it turns out that, from the frame of reference of burnout and organizations, there is a reciprocal causality going on - some dysfunctional aspect of the organizational system contributing to individual burnout and some aspect of burnout further contributing to the organizational dysfunction.)

Burnout IS one of those manifestations of organizational dysfunction. When you see burnout in people, what do you see? Physical, mental, and emotional fatigue to the point of exhaustion; a disinvestment from work and from people - patients as well as co-workers; and you see changed productivity - diminished both in quantity as well as quality.

Now, if you really don't care about the "touchy-feely" (some even feel "optional") issue of individual workers' quality of life, is there any reason for an organization to do anything about its dysfunction?

Well, no; not, that is, if they want/ enjoy/ can endure going through employees like tissue paper, having to re-recruit, re-train, and re-enculture new people (usually highly trained, mind you), tolerate decreased productivity while this laborious and energy-draining process is going on, tolerate low morale that results in absenteeism, poor workmanship, intra-team war, bad outcomes, a poor reputation in the worker community, and dissatisfied customers. No, apart from that, I can't think of a reason to address it.

This notion of "aren't we expected to burn out" might be indicative of the entrenchment of the philosophy of enduring unhealthy, toxic and "anti-wellbeing" worklives.

Imagine this: Say you're a soldier. In the military. Is it a fair statement to say, "you should expect to be shot."? Seems logical, doesn't it? "Soldier". "Get shot at."

WRONG!!!

The vast, VAST majority of soldiers do not, and never will, get shot at! Of those who are in fact sent into combat zones, all attempts are made to AVOID the occasion of being shot at, and - get this - you get shore leave for R&R!

Organizations, many of which today seem to follow some distorted notion of military philosophy, don't seem to realize that:
A) you don't put all your troops in battle
B) you choose your battles
C) you take care of your troops - on AND off the battlefield
D) and you don't work your troops to exhaustion

Addressing your question about what tools and techniques I might use to help an organization explore this Occupational stress / burnout / dysfunctional organization theme:
1) Having the awareness that there's an organizational issue which needs addressing is the crucial first step and opens the door for a willingness to explore creative approaches and solutions.
2) A variety of instruments may be helpful. The Maslach Burnout Inventory is considered the gold standard both as a research instrument as well as a relatively simple screening tool. I find, however, that it serves my population best predominantly simply as a vehicle for talking about burnout - much like the Myers-Briggs or the DiSC does for helping people talk about personality style/behavioral differences. There are a number of other burnout inventories which various people favor. My sense is that their real value comes in simply creating the opportunity to name and explore burnout.
3) Organizationally, the "Staff Survey" built upon Drs. Maslach's and Leiter's pioneering work with individual burnout is a rather comprehensive and systematic approach to organizational function, exploring the key domains contributing to occupational stress/ burnout (write me for contact info if needed).
4) A colleague - who is a co-author of a fascinating book on key principles influencing successful organizational change ("The Seven Streams of Organizational Influence") - and I are adapting the "7 Streams" model to approaching burnout within organizations. Basically, to effectively and durably change any system, you have to do a multi-modal and concurrent approach to all of the "streams" which influence organizational behavior, e.g. infrastructure, leadership (mission and vision et al), reward and coercion systems, communication etc. Quite a fascinating model.

And lastly, with regard to your comment about some people just wanting/needing to be martyrs - it generates an essay's worth of thoughts…but let it suffice to say here: the vast majority of healthcare providers are genuine, compassionate and healthily altruistic. Very, very few - in my experience - are of the pathologic martyr variety.

Do be careful not to falsely label very committed altruistic people who are hanging in there in some very difficult times, often with very difficult clinical or organizational situations, as "martyrs".

Thanks for your question.

Kernan Manion, MD
Work/Life Design
Concord, MA
by Kernan Manion on February 29, 2000
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Question 3 - Hello! I was wondering about how health care is presented to people--industry leaders, workers in the industry, and those receiving services... does how it's presented really make a difference in how well it's accepted?

Can a health care company or person in the health care industry craft their approach to clients/patients in such a way that healthcare becomes less of a "drag" and more of a lifestyle choice for well-being?

What methods would work/do work?

How can the internet approach this?

What works best to help people achieve and maintain a wellness lifestyle?

There has to be some way to provide immediate feedback, since many people just can't or won't wait for the long-term benefits to manifest themselves. Do you have any ideas on how presentation of wellness as a life choice and a personal responsibility can manage this?

Thanks!
by Ingolfsson on February 29, 2000

Answer 3 - I may not be the best person to answer on the issue of "selling wellness" and getting people to take ownership of their healthcare.

But I do have some thoughts about why "illness" may be "easier" to capture than "wellness".

Illness has one in a hurting position. Pain, and the threat of death by illness, are great motivators for some sort of intervention - a trip to the doc, a study or two, some meds, even occasionally behavioral change.

In the absence of frank illness, one is starting from a neutral health position - generally without pain or other discomfort present - and it takes vision and fortitude and perseverance to move toward those things which will improve our lot and a) assist in maintaining health and b) lead us to a greater and more consistent state of well-being. Once you start to get a taste of well-being, and you realize that it really wasn't all that effortful, then you're on your way (often asking "could someone mind telling me why I procrastinated so long…").

Without thinking about what some (not I) would consider more esoteric wellness endeavors, like yoga, meditation, massage etc., look at what it takes just to get people to do basic self maintenance, like taking vitamins. (I mean, when you get right down to it, look how long it's taken to get people to brush their teeth!)

In a piece I wrote for a physicians' newsletter on Wellness, I noted how few people are reported to do prophylactic maintenance on their cars. Why don't they change the oil in their cars every 6,000 miles, especially when it's highly recommended - and there are coupons enclosed!? A simple ~$20 investment. But, no. Most wait until the oil light goes on, or they have a breakdown on the side of the road, or they have some mandatory scheduled maintenance.

How many people routinely floss? Ask any dentist about the prophylactic value of flossing and they'll tell you it strengthens gums, prevents tooth decay etc.

How many people exercise regularly? Routinely watch their fat and overall caloric intake? Slender numbers.

One thing I do know about promoting wellness - or anything that requires effort for that matter - is that it sure helps to make it fun and to do it communally.

Your question would be a fun one to pose to a larger discussion group - what works in promoting "wellness and wellbeing"?

Your comment about people not wanting to wait for long term benefits - we've become such an impatient lot, haven't we?! And yet, part of maturity seems to have to do with accepting that a) we can't - and shouldn't - have whatever we want whenever we want it; and b) almost all worthy enterprises take time and effort - intellectual development, fitness, skill at sports, development of one's artistic sense. There's simply no bypassing it.

Stephen Covey, in "The Seven Habits of Highly Effective People" beautifully refers back to the "law of the harvest" - what you sow, so shall you reap. If you don't put in the effort, you come up with a barren harvest.

Thanks again for your question.

Kernan Manion, MD
Work/Life Design
Concord, MA
by Kernan Manion on February 29, 2000
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Question 4 - Hello! Having worked in a psychiatric hospital for a year, burnout is a very relevant issue, one about which managers in a health care setting (as well as any other setting, I think) need to at least be aware.

The healthcare industry as a whole--whether you're working as a nurse, an aide, a doctor, a tech, a counselor, an administrator--is very stressful as a working condition. You see people in hurtful situations, and sometimes everything you do isn't enough to save or help them.

That being granted, I enjoyed your comments about the inventories being a portal towards talking about the issue within the organization. I think that's terribly important! If you can't identify it and talk about it, it will never get better, and you'll end up losing your best people to burnout.

What are your thoughts on pre-work training about burnout and dealing with the stressful nature of certain work activities? Your example of the soldier comes to mind--boot camp isn't a picnic, and it does help prepare the "boot" for their new career as a soldier, sailor, airperson, or Marine.

Do nursing programs and doctoral training schools explain the burnout possibility? Do they prepare their students for this eventuality (I hate to call it that...)? What are some of your ideas on this, and how do you think training before entering the stressful workplace could help decrease burnout?

Thanks!
by Ingolfsson on March 1, 2000

Answer 4 - Hi Anne Marie, You're right on target with regard to the need for all of us in HC, especially perhaps those who are in a managerial capacity, to name and talk about the reality of occupational stress and burnout. And yet, how many places do you know that actually do that? Not many, in my experience.

And why don't they?
My speculations:
- ignorance of the reality of the burnout and about its profound impact
- ignorance about how to go about it
- feeling like it's too "touchy-feely" to approach emotional issues in the workplace
- feeling that if you can't hack it, you shouldn't be doing the work
- feeling too stingy to put forth the $ to a) learn how to set up a burnout prevention program and b) giving employees the time - paid for - to address work-related issues
- feeling fearful that it'll open a floodgate of issues and emotions (perhaps pervasive worker burnout [in a high burnout environment], or challenging leadership's stance on some issues et al.)

Should there be pre-employment training about burnout and its prevention? I certainly think so.

Imagine for a moment if we were talking about a mortality rate - "if you come to work here, you have a 5% chance of dying" - well, that's rather important information. Or "you have a 5% chance of getting exposed to 'sick building' syndrome" or "leukemia"- whatever. That's important information that a) let's you make an intelligent decision about the risks and b) allows you to take some prophylactic measure to prevent it from happening to you.

Now, why can't we apply this same reasoning to occupational stress, compassion fatigue, secondary traumatic stress disorder and burnout? Ignoring the reality of them is not going to make them go away. But, of course, people are big into denial about things that make them uncomfortable.

If a job gave 25% of the people a heart attack, you'd say "wow, I don't want to go near that one - or at least the pay and benefits and prophylactic measures had really better be in place". Well, burnout IS the emotional equivalent of a heart attack! And we're seeing an incidence of burnout at somewhere between the 30-70% range in various specialties. Yes, we most definitely do need to be talking about burnout occurrence and treatment and prophylaxis. Why? Not only because of the direct effects of burnout - but because of the subsequent damaging "career mortality" and "heart and soul morbidity".

You mention the powerful impact of working with high intensity populations - they can be psychiatric, obstetrical, oncologic, pediatric, etc. - many, perhaps most - clinical specialties have their share of high intensity work - and some certainly more so than others.

In working with such populations, we are bound to be affected by the power of what we are witnessing. The very act of empathy necessitates a 'taking in' of the event and at some level processing it as if it were our own. When you 'take in' the awesome life struggles that many are facing, it necessarily exacts an emotional toll. Where do people in healthcare take all of that? When you witness the anguish and chaos of the emotional turmoil of psychosis, or the anguish of progressive medical illness, or the horror of trauma - where/how do you process these?! I would argue that not doing so continues to erode our spirits and our resilience, and in so doing, deprives others of the fullness of our genuine presence and the richness of our skills. These events are obviously taking a significant emotional toll on empathic individuals. And, incidentally, are silently taking a toll concurrently on co-workers.

In trauma work, there is an intervention known as "critical incident debriefing" - this has been repeatedly shown to be quite helpful in both dismantling the secondary traumatic stress cascade AND in creating a support community among providers.

One of the interventions that has also been helpful is, for lack of a better term, "high intensity situational preparation". In one study of nurses, it was found that if you simply surveyed the existing staff about what are the most stressful aspects of the clinical (and non-clinical as well, though not germane to this particular intervention) work and then developed training modules and rehearsal role-play exercises and effective problem solving around these, you resulted in much lower stress and much higher job satisfaction. Brilliantly simple and unfortunately not sufficiently implemented.

I'd certainly like to write more about this but can't due to time constraints.

What can organizations, school and training programs do?
a) teach awareness of the reality of and manifestations of occupational stress, compassion fatigue, secondary traumatic stress disorder and burnout;
b) create protocols for responding to the warning signs of burnout;
c) set up forums and workshops and support groups for people working in high intensity environments;
d) create a caring workplace community and a philosophy of concern for each others well-being. (Can you imagine that! An environment where someone genuinely cares how you're getting along by asking "how are you making out? Are things going okay?" (This may seem downright delusionally idealistic to some.)
e) de-stigmatize burnout - remove it from its usually accompanying shame. It's not shameful. Is it shameful for a fireman who's just brought out a badly injured kid from a fire to go through a period of mourning? Is it shameful for EMTs to go through post traumatic memories of accidents and have lingering sadness and perhaps revulsion? No. It's part of the process. So let's start dealing with that reality. Ignoring the reality of the stress and its impact on us is not going to make the tremendous impact go away.
f) Create genuine mentoring programs where people are brave enough to share their feelings - not some emotionally aloof pathologizing "clinical supervision".

Thanks for your thoughtful question,
Kernan Manion, MD
Work/Life Design
Concord, MA
by Kernan Manion on March 1, 2000
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Question 5 - In reviewing the week's essays, questions and responses, I found myself asking "is there something larger here than just "ocupational stress" and "burnout"? Is there perhaps a larger crisis of meaning, of spirit, within healthcare?

So, I wanted to have this last opportunity to explore that question.

I also want to thank HealthBond for the opportunity to host this forum and wish them well in their efforts to create a community of dialog within the business world of healthcare. by ktmann on March 3, 2000

Answer 5 - "Passive" Burnout, The Erosion of Spirit, and the Crisis of Meaning

I've described how burnout may be contributed to by the organization, by the individual him/herself, and as a result of some complex interaction of the two.

Is it possible that pervasive situational factors, i.e. the "environmental climate" of healthcare, can also conspire to produce a widespread epidemic of burnout, independent of individual or organizational factors?

In other words, can a host of factors, independently relatively minor, or at least manageable, become additive [even exponential] in their effect in producing burnout within individuals and organizations?

In examining the literature of occupational stress and burnout, I've discovered that, in fact, this very phenomenon is likely playing a much more prominent role than any of us might have ever imagined. Here's how.

When we look at the triad of manifestations of burnout - exhaustion, detachment, reduced accomplishment - we see that individually and organizationally, there are clearly contributors to each of these.

Can we envision that - beyond our individual psyches and beyond our own organizations - powerful factors are at work contributing to these core symptoms?

Let's say that my paperwork/charting component is taking up increasing amounts of time. That obviously adds to my workload. Let's also say that, no only is it a requirement of the government, but also that I'm constantly aware of the medico-legal and financial implications of not being detailed in my charting. So, I need to even put in more effort (i.e. "work"). Now, meanwhile, my patient load has not diminished; in fact, it has likely increased, due predominantly to the impact of "third-party mandated throughput" [don't you just love that anonymous "third party"?]; i.e., see more patients quicker.

So, I begin to get - usually insidiously - more fatigued. The increased work/effort takes its toll. The combination of increased paperwork, more patients, and quicker visits (not to mention the enormous hassles involved in getting paid - for those, like me, who face that task as well), takes an inordinate amount of energy. AND, one feels progressively more disgusted with it - it's more meaningless, CYA hassle work, preventing one from doing the essence of one's job.

Now, examine this carefully!

What do you see happening in this micro-vignette?

System-induced fatigue - a conspiracy of factors within a quite dysfunctional system is leading to exhaustion! Physical, mental, and emotional exhaustion! More patients, more rapid thinking about diagnoses and their implications, more worry about their illnesses, their negotiating the system, their getting taken care of, our getting sued for screwing up, or conversely getting penalized for providing "too much service" etc. Wearying.

System-induced progressive detachment from one's patients - you simply can't devote time to people in the same way due to the increased array of other obligations, namely increased patient load and "throughput" (a factory production term disgustingly applied to healthcare services!); therefore, there's a pulling away - often unsatisfactory, and frequently painful as well, for both parties in the engagement - and a consequent loss of "connection".

System-induced reduced sense of accomplishment - one doesn't feel like one has made the best accomplishment with this or that patient. And, in fact, because of both increased volume of patients as well as decreased time with patients (and realize - these in fact ARE two separate phenomena!), one isn't getting the same degree of completeness of work done. Now, there's another component to this reduced accomplishment. Remember when Marx (yes, Karl - don't worry, the cold war's over, you can speak his name) spoke about worker alienation at the dawn of the industrial age? One of the biggest problems he saw with industrial capitalism was that it removed workers from the end-product of their work and therefore contributed to a sense of alienation and anomie. (Of course, he wasn't too pleased that they didn't get a share of the profits either!). What happens if you take away a sense of reaching some satisfactory "endpoint" of your handiwork? It robs you of a sense of completion, of accomplishment, and of meaning.

So, looking at this from a larger systems perspective, what we see is that the healthcare delivery system itself, encompassing all of the organizations and providers within it, is conspiring to produce burnout in EVERYONE who proposes to undertake its care-giving work! EVERYONE!!! PASSIVELY!!! And usually insidiously.

A malignant system of causality is in place which is contributing to exhaustion, progressive disconnection (read "detachment") from our patients, and an awful sense of reduced accomplishment (we've become just "piece workers" in a healthcare assembly line - at some level in our subconscious we're saying "what happens to you, dear patient, in the next department, the next piece of treatment, I don't know, and worse, I don't and can't care" - isn't that the necessary internal dialog? Isn't that necessarily in conflict with our core values of caring and wanting to help reduce suffering and help to heal? So that, by necessity, if you happen to "care", you're going to get fried - emotionally spent. And if you "don't care", you're going to get fried, because "not caring" is incompatible with being a "care-giver". But either way - Fried. Baked. Burnt. And Burnt Out.)

PASSIVE BURNOUT!!! A loss of coherence to our work, a devastating loss of meaning. We've lost the thread. We are just necessarily "going through the motions" - as "vendors". Truly a crisis of meaning, of the very meaning of our life's work; and truly a crisis of spirit!

Progressively - and sadly - we are seeing the cynical resignation of many formerly altruistic and deeply compassionate and gifted healthcare providers. It is a painful loss of spirit. It forces us to go deep within and ask ourselves "what is going on? What are we about? What is the meaning of our work? Is it possible to do this work and uphold our deeper values?" In order to begin to address this malignancy, we must find a way to collectively name this passive burnout, to explore it, and to find ways to restore genuine meaning to our work.

Kernan Manion, MD
Work / Life Design
Concord, MA
by Kernan Manion on March 3, 2000
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Question 6 - As I read the last Q & A, Kernan it is very sad to me. I think there are so many signs of "passive burnout" in our industry. Yet, we all over look it and continue on. Why? This can not be a good feeling to "just go through the motions every day." We have all invested a lot of time and money in education and training--this can't be the way it is going to be. With visionary issues at play, it is very difficult for any organization to take time out and deal with emotions. It's that mentality that "this is the way it is".

It doesn't and shouldn't continue to be this way. If we want it to change bad enough it will. So how many want it bad enough? Are we caught in the familar area that "yes, it is bad - but I know what to expect from it mentality" Fear of the unknown or "it might be worse than what I am already dealing with" or it is "I just don't know what to do about it."

I know we all know this exist. Kernan have you or anyone else done any research on this area? Why we take this approach - this mental thinking that ruins our industry development and how to break out of it? Because we are going through the motions on all levels gov't, consumer, caregiver, leaders without any real solutions. If we could just see what it could be - what it really could be. by tammy on March 3, 2000

Answer 6 - Hi Tammy, Thanks for your comments.

Well, it is sad. But, ironically, hopeful. (Am I the eternal optimist, or what?!)

Dysfunction is often painful, and pain motivates us to do something to change. And change does take place when a critical mass of people decide it must.

We have seen the capacity for enormous social (read "system") change in this era: racial integration; changing roles of men and women vis-à-vis relating
and parenting; our attitudes toward the environment, and toward garrulous U.S. behavior on the international scene (well, some Republicans excepted).

We clearly have a far ways to go on many issues – e.g. widening disparity between rich and poor; backwards attitudes toward education (“defense” over “education” - with concomitant cutbacks in cultural and sports and library programs in schools etc.), gluttonous consumption, breakdown of real “community” etc.

Maybe we’re on the cusp of some powerful social change which, by nature of its painful alienating power, forces us to come together to review the systems we have in place to see if they’re working – for everybody.

Healthcare can no longer be a composite of solitary duchies each with separately vested interests. Some of us increasingly realize that unless you gather all the key players around the table – patient, provider, institution, payer, employer, supplier, government and all other relevant stakeholders – and craft mutually satisfactory solutions for all of the affected players, you’re going to continue to have dissent and turmoil.

To do that, we need to have forums whereby participants can clearly articulate not only their positions but their core needs. That’s the key behind all conflict resolution – getting people together to find a win/win solution for the achievement of their core needs.

How do you do that? Communication, communication, communication. We’ve got to make the space for communication.

And it will take great fortitude and perseverance and vision to keep the flame alive, both within our worklives as well as toward this goal of crafting a system which meets everyone’s needs. (I imagine that the evolution of our truly great and unique democratic republic necessitated
these very virtues!)

Allow me to be more pragmatic and less pie-in-the-sky for a moment. A practical example comes to mind. One of the more obnoxious, even toxic, elements of being a doctor is being on night call. Witness the evolution of a creative solution: 1) shared call among several practitioners (and then sometimes even between entire groups!). That’s ingenious! Here’s a collaborative solution to a challenging problem. And the bridge was successfully built! 2) Next comes – a call service! Here in the Boston area there is a pediatric as well as a cardiac ‘round-the-clock call service that patients can call in to to get definitive answers to their problems. Without having to impose upon an exhausted doc’s private life. Who knows, maybe next will be the development of ‘round-the-clock walk-in centers for non-emergency matters, like medication side-effects, or running out of meds.

(Get this! – I’ve got colleagues who get woken up for “I’ve run out of meds” calls! Or “Doc, is this a side effect?” calls! My BP goes up just thinking about it! And with the omnipresent possibility of making a mistake, every
one of these sub-routine calls becomes a weighty matter – everything’s got to be thought through – one screw-up and the patient might be harmed, or you might make a mistake. And get this – docs do this for free! Imagine!!! A doc
can’t live like this! So, could one imagine a situation where docs have, say, a screening service that says “we’ll be happy to contact a doctor promptly for you; your MasterCard will be billed $___”. But it’s going to
take docs some chutzpah to say “no more of this arrangement”. Alas, right now, they’re so numbed, and buying into guilt-induced masochism, that they
can’t muster it.

Or here’s another. Nurses doing all this infernal charting. I know some places where the nurse’s entire day – pardon a bit of hyperbole here – is spent in the charting room. The NA’s and LPNs do the real patient contact work, including meds and dressings etc. Excuse me, but is this not crazy or what!? Might we get to a system where the charting is done the same time as rounds? Or perhaps interim notations dictated. But again, it’s going to take
RNs with chutzpah to step up and say “brothers and sisters, we’re changing the game.”

And another. We’ve got the stupidest, most inefficient bookkeeping system of medical commerce currently operational in the known world. Third – yes even
fourth! world countries have more advanced systems of commercial transaction (“one unit of service = three conch shells; payable on receipt of service, thank you”). Docs and institutions are “taking” – i.e. accepting – these
ridiculous insurance plans, each company offering ~ 20 different variants to its “subscribers” – how is ANY enterprise going to keep up with this many policies, co-pays, deductibles, secondary and tertiary payers etc.? It’s
just about driven me and my staff mad! And so I’ve taken the novel stance of saying “the gig's up” – no more HMO’s and soon, no more insurance accepted as “payment” – ‘cause it ain’t”. But it’s going to take a group of us to say
to the payers “gosh, that’s a wonderful idea you have of decreasing utilization by charging a deductible and a co-pay. Tell you what. You collect. Pay me my rate. Period.

We’ll be doing a great service – both to patients and towards lowering our overall medical overhead expenses. We will have a) just saved the consumer/society about 20% of the gross amount of the cost of medical care by dramatically wiping out all of this silly and exhausting claims submission and collection effort – and b) ten-to-one, we’ll see a heck of a lot of reeling in of these silly programs. (I mean really! Can you imagine if your grocer had to go through this!!! Collecting co-pays and deductibles and recognizing limitations on what meat you could buy! (I'm sorry, Mrs. Smith, your food card only allows you to buy ground chuck. But also, I see there's a $4.95 co-pay; and you have a $100 deductible - oh, and you'd like your secondary food card 'FoodforThought' to pick up the balance 6 months from now?) There’s no computer program built today which could handle it!!!
Half the grocery’s personnel would be have to be support staff for the cashiers!!! So, when do the docs, and the providers, and the institutions, and employers, and PATIENTS (yes, be brave – imagine, PATIENTS!) get together and say “you know, this is not working for any of us – how can we best change this?”

It’s going to take a huge amount of talking with each other – genuinely and collaboratively – and not from the vested interest standpoint that is so prevalent today. And we need to create those forums. And I’m delighted that
HealthBond is in fact one of those! And I want to be an active part of it as well!

But it takes vision, and fortitude (that’s the chutzpah), and perseverance. And of course faith and trust. Faith that we actually have the ability to envision and collaboratively change; and trust in each other and in the
wisdom of the larger process.

I do know this – that once we mobilize that creativity and energy and spark the tinder box of that collaboratively envisioned change, we‘ll at last be able to recapture our vitality – and restore to health the very soul of medicine.

Godspeed to us all.

Kernan Manion, MD
Work / Life Design
Concord, MA
by Kernan Manion on March 3, 2000

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