At one point during his physician training, Dr. Prasanna Tadi came close to leaving medicine.
“You come, you work, you go, and no one cares about you,” he recalls feeling at the time.
Some of his fellow residents and trainees did, in fact, fall to the many pressures they faced and left the field.
Now Tadi, a neurologist with CHI Health and assistant professor in Creighton University’s School of Medicine, is working to do something about it. This month, he’ll launch a study to investigate a possible remedy for burnout.
Studies of physicians, in particular, indicate rising rates of stress and burnout at levels exceeding those in the general population, and concern has grown about depression and even suicide. Burnout also has been documented among other health professionals.
“My thing is, nobody should go through this,” Tadi said. “It’s almost my giving back to medicine.”
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He and a team of residents will look at whether increasing time spent with patients and cultivating deeper connections with them can boost the well-being of health care professionals. Creighton’s study is one of 33 selected this year from among 200 proposals through an initiative of the Accreditation Council for Graduate Medical Education, the group that sets educational standards for preparing physicians.
Tadi already is using the program with physicians at Immanuel Medical Center. Next month, it will launch with Creighton internal medicine residents, who are doctors in specialty training. Later, plans call for offering it to medical and dental students and eventually expanding it to Creighton faculty and additional CHI Health practitioners.
Burnout not only affects individual health care providers, Tadi said, but also the care they can provide patients. It can decrease the quality of care, increase risk of errors and reduce patient satisfaction.
It also can result in personnel losses that the health care system can ill afford, given shortages of physicians and other health care professionals, which are expected to grow in future years.
There are also economic costs. Replacing an existing physician, he said, can cost between $500,000 and $1.5 million.
A number of organizations nationally and locally have increased attention on physician well-being in recent years. The National Academy of Medicine has formed an “action collaborative” around the issue, making it a national priority.
Dr. Jeffrey Gold, chancellor of the University of Nebraska Medical Center and chairman of the ACGME’s board of directors, said he believes that the field as a whole is making progress on the issue because people are talking about it.
He speaks about it at every commencement at UNMC. The ACGME, in addition to the initiative that funded the Creighton study, also has added wellness and resiliency to the six focus areas for which it provides feedback to teaching hospitals.
“Progress is being made because we have tools to measure burnout and stress,” he said. “We have destigmatized the conversation broadly on the national scene, and we’ve created a large number of tools to deal with it on an individual and national level.”
Historically, the issue was not discussed, he said, even though it is a challenge the health professions have long faced. Taking care of sick people can be a stressful thing.
Early on, there was some thought that the current burnout rates reflected a flaw in the new generation of physicians in training. But those involved in the issue have learned that that’s not true. “These young men and women are just as strong as any generation we’ve had,” Gold said. “The difficulty is that the work requirements ... are just increasingly demanding.”
Those requirements include more time on clerical tasks such as electronic medical record-keeping, as well as the complexity of the illnesses and social needs they see in patients, and the moral injury providers face when they find out that insurance won’t cover a procedure or medication a patient needs, or learn the patient can’t afford car fare for a follow-up visit that’s clearly needed.
“That produces a sense of failure and a sense of questioning the core of what it means to be a physician,” Gold said.
The basis of the Creighton study is an intervention called CHEER, which stands for celebrate, hearing, expertise, engage and recharge. Each element will be used in three different settings.
The first is hospital rounds. Teams of residents will select a patient with a complex social and medical background. At the start of the workday, teams will meet with the patients and their families — the residents will be free of pagers and screens during that time — and talk with them about their backgrounds and hobbies, as well as their understanding of their medical conditions and challenges in accessing health care.
“This is all personal touch, back to basics,” Tadi said.
The second is an monthly hourlong meeting. During the celebrate portion, the team will invite a recently discharged patient back to thank them, talk about their hospitalization and celebrate the team’s good work.
“Usually we don’t see them again,” he said. “Now we’re keeping the patient at the center.”
The team also will ask patients how they can improve, Tadi said. Meetings will include talks on various topics by wellness experts.
The third element is emails that will, among other things, recognize residents’ personal and professional accomplishments. Another aim is to build community.
Participants will take surveys designed to score well-being before, during and after the program and for the following two years.
Tadi said the program isn’t the only potential solution to the problem. The medical community also needs to address it on other levels. He’s one of 15 neurologists from across the country selected to participate in a burnout initiative launched by the American Academy of Neurology.
The problem also has its own sort of continuum. Suicide, experts say, usually isn’t a result of burnout alone but of mental health problems that aren’t being adequately addressed. Mayo Clinic researchers have estimated that up to 400 physicians a year die as a result.
Burnout differs from mental illness in that it’s more about isolation and losing perspective. While mental illness is treatable in its own right, burnout can be addressed through tactics such as seeking support or contact outside work, doing yoga or taking time away.
Locally, other health systems have their own in-house initiatives or offer assistance through their employee assistance programs.
UNMC has taken a multipronged approach, which currently is featured in an American Medical Association magazine. Gold in February 2018 appointed Dr. Steven Wengel, UNMC’s former chairman of psychiatry, as vice chancellor for campus wellness at UNMC and the University of Nebraska at Omaha. The university also has launched an app with a stress survey and tools to relieve stress, among other measures.
The Metro Omaha Medical Society began offering an anonymous online assessment for physicians, medical students and residents in February 2017. Since then, 130 professionals at all phases of training have completed it. Of those, 49% ranked in the most serious level of stress, said Carol Wang, the organization’s executive director. Those showing signs of distress are referred to telehealth experts or local professionals. Nationally, various sources estimate that about half of all physicians show some signs of burnout.
Wang said the local medical society also has added some peer support networks, including a closed Women in Medicine Facebook group for female practitioners and another for physicians who treat physicians. The organization also continues to host speakers on a variety of topics, including how to make medicine better.
The organization began the initiative to see whether a local intervention could help. The group, she said, also saw itself as a kind of neutral third party that could operate outside of health systems and offer another measure of anonymity.
“I think every organization nationally that deals with medicine and health care is trying to figure out what will move the needle and what will help,” she said. “There’s not going to be one pathway that is going to address this ... and get us to a healthy health care system.”
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