Cristina Ferrone, MD: Improving Care for Rare Cancers
Episode #30 of the Charged podcast
PodcastJun | 26 | 2019
As modern technology allows us to plug in to work and life on the go, at any time, from almost anywhere, work can now creep outside of the 9-to-5—and into the rest of our lives. This can leave a person feeling stressed, exhausted and burned out. Practicing medicine can be difficult, both physically and emotionally, and research has shown it is a field prone to burnout. And while burnout is not a phenomenon unique to medicine, a 2019 Medscape report found that nearly half of physicians surveyed reported feeling burned out by their work—and more women than men reported feelings of burnout.
In this bonus episode, we ask clinicians from throughout the hospital to share their experiences. They discuss how they are confronting burnout in their own lives and explain how Mass General is working to help physicians prevent burnout from taking hold.
Our lives are more connected than ever before. Modern technology allows us to plug into work and life on the go, any time, from almost anywhere. And while there is great power in this, it is also means that our work tends to creep outside of the 9-to-5 and into the rest of our lives. This can leave a person feeling stressed and exhausted, and can even lead to medical complications.
While burnout is not a phenomenon unique to medicine, a 2019 Medscape report found that nearly half of physicians reported feeling burned out by their work. This statistic in and of itself is concerning, but what really caught our eye was that the same report also found that more women than men reported feelings of burnout.
Over the past few months, we’ve explored this topic with the women of Charged. We wanted to learn about their experiences, to find out how they are tackling burnout in their own lives, and understand what is happening on an institutional level to help everyone better manage the stress inherent to medicine—and to modern life.
This is a collection of what they’ve shared.
Burnout is generally defined in terms of three elements: exhaustion, cynicism and feeling less capable at work. But if you’ve ever felt burnout yourself, you know that it can be difficult to spot as it creeps up on you.
Dr. Noopur Raje, director of the Center for Multiple Myeloma at the Mass General Cancer Center, watches for one warning sign in particular.
Noopur Raje: Being a physician is a very demanding job, and it’s not just physically demanding; I think it’s emotionally very demanding.
Burnout is when you don’t enjoy doing what you're doing, that's when burnout sets in. If your work brings you joy, there's not that much room for burnout. So if you see that work is becoming more of a chore, then I think you need to reexamine what it is that you need to change about work. And being open about that is going to help you with burnout, in my mind.
So if it means you're in clinic all the time and that's what's causing the burnout, allow yourself the flexibility to change that. You have to be able to change. And we all get stuck on a path and we just want to go, go, go, go, go..
It's usually when you think going to work is a mundane thing to do. That's when burnout creeps in.
Amy: To really, fully deal with burnout, however, we may need to reframe how we think about it. For psychiatrist Dr. Cristina Cusin, it’s important than any discussion of burnout goes beyond the individual.
Cristina Cusin: For years I was really annoyed with the terms "burnout," it just did not resonate. It's something like putting the blame on the individual. But if you think about medical school and residency, one gets at the end of a residency with a lot of skills to deal with impossible demands – shifts of 36 hours, at least in the old days, and seeing patients at ungodly hours; and being available for your patients. It's not for lack of abilities or lack of energy or lack of will. So the burnout in my mind put too much focus on the person and not enough on the system.
All the old suggestions – you have just to do mindfulness; you have to exercise more – it annoyed me beyond belief. I was just angry. I said that's not the point. I don't have time for my life, how can you tell me that if I do some mindfulness and some exercise, everything's going to be better?
If you are a clinician, you are bound to help your patients in the best possible way. But there is another imperative of being productive, seeing a certain number of patients, writing your notes in time, and clicking of the boxes. The death by a thousand clicks.
So you have all this barriers to provide the best possible care that you can.
And this I think, this is the systemic issues that are related to the frustration, where you can't do a physician job because you're doing secretary job, you're doing administrator job, you're doing the billing department job, you're doing a lot of other jobs. And this prevent you from having a good relationship with the patient.
Amy: Success can also bring its own challenges. For many professionals, success in career begets more success….and also more work. Dr. Sareh Parangi, an experienced thyroid surgeon, has learned from experience the importance of having a good support network when burnout creeps in.
Sareh Parangi: I remember a very distinct time when I was working on a grant and administrative duties that I had for the Association of Women Surgeons, and I had a lot of patient care stuff. And at some point on a Friday, I actually couldn’t imagine driving myself home. I actually had to call my husband and say, “Why don’t you come pick me up because I want to come home and work on this grant.”
And he was very smart because he did pick me up, but drove me to a restaurant where we could have some wine and relax and talk about things and try to decompress.
I think when bad things happen, if something bad happens to a patient, you pile up a lot of guilt on yourself. Especially as a surgeon, you really feel responsible.
And then everything else piles up. Administrative work, EPIC. It’s a nightmare for everyone. National stuff that you have, your kids, your parents. For a woman I think that's particularly true. You're taking care of your kids almost at the same time you start taking care of your parents, sometimes, and that can be challenging.
Amy: Dr. Parangi has also learned from experience the warnings signs to watch for.
Sareh: I certainly didn't sense it until I couldn’t get up off the chair and go home. It’s like that whole frog in the hot water story. I think it happens to you so slowly, and your mind gets numb, and you sort of don’t notice it.
But I think certainly things like you become depersonalized. You don’t care anymore, you don’t care about your patients, you don’t care about your colleagues. You become very cynical. So I think if you notice those traits, you don’t do anything you enjoy anymore. You're only doing the things that are required. So if you notice your relationship is going south with your spouse, with your children, you have a short fuse, you're exhausted, you're not eating well, you're not able to sleep, you're worried all the time. I think those are definitely signs for me that that's happening.
But I don't know that I always have noticed when it was happening.
Amy: It's important, too, to encourage people to take the time they need for themselves and their family, which palliative care specialist Dr. Vicki Jackson has learned over time.
Vicki Jackson: I have felt crispy at times I call it. We spend a lot of time in our field thinking about burnout and resilience.
We have to encourage clinicians to claim that space for themselves. I remember early on in my career, it was like a weekend and I got paged for a patient who was really sick in an outside hospital, and my daughter was about three at the time, and she stubbed her toe when she walked into the room and she was crying. And I had this watershed moment, like I thought, “It is not her fault that her mom does this really complicated thing where I am always caring for somebody’s only mother or only son. It’s the stakes are emotionally high.”
And so I said to the family on the phone, I said, “I am so sorry. I need you just to hold on one minute.” And I comforted her and shooed her to her dad. And it took 30 seconds, but there was something very powerful that I was claiming that space for my family and still able to be a professional clinician.
Amy: Technology has monumentally changed the practice of medicine. Electronic medical records allow clinicians to better track a patient’s care over time. Patient communication platforms allow patients to easily make appointments, access test results and ask questions. As these tools have become the standard, however, clinicians have felt the burden of increased documentation time, and many have experienced the perceived pressure of patient communications at all hours.
Physiatrist Dr. Kelly McInnis has learned the importance of setting boundaries with herself and her patients to help stave off burnout.
Kelly McInnis: The administrative burden sometimes becomes overwhelming. But you know, I try to keep it in perspective. And I think that we as physicians can control a lot of it ourselves. and I think this is true of many different professions--we make ourselves available way too much.
We make ourselves very accessible through email, through text, through phone calls to our patients. And so, it's very hard to turn it off. The way that I've dealt with that is to set very strict limits on the time I spend on my phone and the time I spend on patient care outside of my clinics.
When I'm at home, I want to be with my kids. I do not want to be working. I do not want to be answering patient calls in the evening when I'm putting my children to bed. So I set limits with patients, and I'm very clear about my expectations with them. It's easier for me to do that in my field because I do not have emergencies. Patients' questions can generally wait until working hours. They know how I feel about that, and I'm very responsible about getting back to them soon, so they know they can rely on me to do that. It does not need to happen after hours.
Amy: Some days it feels like burnout may be an inevitable part of modern life. But that doesn’t mean that our only option is to give in. The women we spoke with are taking action in in all kinds of ways their own lives. Dr. Sareh Parangi has developed a simple three-step method that she uses when life becomes overwhelming.
Sareh: The biggest thing is coming back to my original values and trying to lighten the load. Like trying to get rid of the things that I don’t enjoy has been a helpful tool for me. To sort of put things in piles and say, “What do I enjoy doing? What do I sort of enjoy doing? And what do I absolutely not enjoy doing?” And then I get rid of everything that I don’t enjoy doing.
And then there's mission creep that things you don’t enjoy doing starts creeping back into your life because you kind of say yes to everything. So then you got to redo that whole exercise again. So I sometimes recommend to people to just do that exercise once a year and try to also not say yes to everything. That's a hard lesson to learn. But women, especially, have trouble with that.
When someone asks you to do something, just say, “Wow, that sounds great. Can I get back to you?” And then take 24 hours to think about it. Does it align with your goals? Do you have the time to do it? Do you want to do it? And then if all three answers are yes, then email them and say, “I’ll do it.”
Amy: Leaders in any institution play an important role in creating the workplace culture. This includes thinking critically about how individuals spend their time. Making sure that team members spend their time doing meaningful work can have a big impact, according to nursing leader Hiyam Nadel. The practice of medicine and patient care is hard work, both physically and emotionally, so she encourages the people around her to take care of themselves.
Hiyam Nadel: I think what we're hearing from our bedside nurses, it's complicated. It's very hard to take care of patients. And I think the more they're burdened, it just gets more and more difficult to take care and stay. It's not sustainable. And I think you see nurses leaving, as well as physicians. And I think it's really something we have to pay attention to.
You know, we can do it in very small ways. I'm teaching my managers now to really look out for their staff. If they're constantly putting in more hours than they need to be, you need to watch that; why is that happening? Working with the staff to really get them to be able to leave on time and things like that.
So that's just, trying to reach a work/life balance, I think that's the first step. And I really mean this, I really mean this – is to really get a group together. But to really look at every step of the way for everyone – nursing, physicians – and what can we take out of that day for them to really just help them manage all.
Amy: When she thinks about leading her team, Dr. Noopur Raje has a simple goal.
Noopur: Really focusing on people’s strengths and trying to get the best out of them. Because everybody has, you know, things that they love doing and they're really good at doing that. And really capitalizing on that and honing in on that for them, I think, has been useful. People who feel accomplished, people who feel appreciated, people who feel that they are--you hear them.
You know, you're not going to see a lot of dissatisfaction. You're not going to see a lot of burnout there. And I think doing that and trying to bring the best out of people is really, really important.
Amy: But it’s also helpful to think about resilience as a skill that can be built to help individuals prevent burnout in their own practice. The Department of Palliative Care, led by Dr. Vicki Jackson, has developed a three-year curriculum to help young clinicians learn those skills.
Vicki: I think when I first started as in this leadership role as Division Chief, I had a very naïve view about what the issues were, sort of you just have to tell people, “Don’t stay until 7:00.” As it turns out that doesn’t work.
And I think that what I have realized is that there are systems issues, and there are personal issues related to burnout, and the system issues I need to be responsible for as the leader, right? So, there is this really helpful scale called the Areas of Work Life Scale which talks about community, fairness, values, workload.
We have a three-part approach that we use to think about burnout and resilience and sustainability in the Division of Palliative Care and Geriatric Medicine. So, we have with others developed eight to 10 hours of a resilience curriculum, which is meant to help clinicians be able to understand what is going on for them.
And so part of this resilience curriculum is really thinking about these different issues, boundaries, cognitive distortions. In medicine we are a really crazy perfectionistic group where if something doesn’t go well we are much more likely to blame ourselves and believe that if somebody else had been doing it would have gone better. So, how do we think about these cognitive distortions in a way that helps us be our best selves and be kind to ourselves?
Boundaries are really important and, we don’t teach that in medical school or in nursing school, and we have to have a way that we can work as a team and have clinicians feel like when they leave the hospital, they can leave the hospital and know that that patient is going to get excellent care and they’re going to be fine if they’re not there.
Then in the second year we do some work with having our providers be able to have one-on-one supervision to talk about these difficult patients and patient scenarios. What we find is our early junior faculty often will say things like, “Well, if that clinician were seeing the patient, it would have gone better. It’s because it was me.” And really the only difference between somebody more senior and that junior person is we would have known that it was going to be tricky and probably wasn’t going to go well, but they often early on have not understood all these dynamics and family dynamics, and in medicine and nursing often are not trained in those things.
So, that kind of one-on-one supervision to be able to talk through cases, to think about, “Is there something I should have done differently? What do I need to understand about psychologically what is going on?” has been really helpful for our faculty.
And then the third year we do something called a Balint Group where we have clinicians come together to be able to talk about patients who are challenging for them to begin to build these skills up to think about what’s hard. And basically I say to our faculty, “If you’re going to join our faculty this is what I expect you to do,”
We have to stop thinking that this isn’t a skill. It’s a skill like anything else. And I think we do everybody a disservice by saying, you know either, “Well, some people can cut it and some people can’t.” I think that is just crazy and we lose some really, really talented clinicians when we’re, when we think about it in that way. So, I think we have to have a much more sophisticated way that we view this work.
Amy: As leaders, many of the women we talked to are also trying to change the relationship their teams have to work. Bonnie Michelman, head of Police & Security at Mass General, has a helpful rule for her employees.
Bonnie Michelman: I try to make sure that if I sense that people are getting anxious or burned out or overloaded that I’m talking to them about it, I’m helping them to prioritize, or making sure they’re doing that. I try to help people be organized, because that helps them with their own prioritization and burnout.
And I often tell people, “Don’t call in sick. Call in well. If you need a day just to relax and have fun just call in and say I’m calling in well.” I don’t want anyone to feel that they can’t do that. It’s their time. And we all need to be rejuvenated and revitalized and people need that in different ways.
Amy: And it’s also helpful for all of us to remember that finding and maintaining work/life balance can be difficult. Dr. Vicki Jackson reflects on that challenge.
Vicki: One of the big pieces is to have, both in my home life and my work life, people who I can count on to help, to be there. This idea of work/life balance is a real fallacy. There are times when one thing is taking more center stage, because there is something that is going on, and something else is less, right?
Like we just had my son’s Bar mitzvah. The family world was taking a whole lot of energy. There are times if I am going to give 10 talks in Brazil the work world is spending more time. I feel really fortunate that in both of these worlds I have groups of people where we have each other’s back, and we can think about, how can I help you because you’ve got this going on right now at work or my husband and I can talk that through about how we can support one another.
That has been the most important piece. And also realizing it’s not realistic to think like I can juggle every single ball and it’s going to be okay. That is, I think, this perfectionism that actually adds to these people feeling badly about themselves and feeling like they’re just not cutting it when it’s just not realistic.
Amy: It’s also important to recognize that we all need time for ourselves. Sareh Parangi tries to follow a simple rule we’re all familiar with.
Sareh: Like what they say in the airplane, put the oxygen mask on yourself before you put it on others. I think it’s really key here.
A lot of surgeons, especially when they're young, spend so much time on little things for their kids and stuff. Some of those things you can outsource and it’s okay. Don’t feel so guilty about those things. Outsource those so then you have some time to exercise and you have some time to think about things and decompress and take trips and vacations.
So I try to model some of those things
Amy: And for all of us, it’s important to recognize that we are all works in progress. Dr. Kelly McInnis works hard to convey and lead by example.
Kelly: As a leader and as a mentor for young residents and young fellows, I think the best way to go about that is to set an example by how I operate, how I enjoy my job in terms of satisfaction and how I balance work and life. And I think that's the best way to provide that mentorship and be a role model.
Now, I'll give them feedback along the way in terms of ways to accomplish that. And we all have challenges, and I'm not the best example. I'm a work in progress. But I have years of experience on them, so I can tell them the things that I've done right and the things that I feel I could do better.
Amy: But the consequences of burnout are not solely individual. In the health care setting, they can impact not just physician wellness, but also patient care and the functioning of entire health care systems. Because of this, it is essential that leaders and health systems take note. And take action.
At Mass General, the physicians’ organization has taken this to heart. Internal research has found that burnout is a challenge across the organization, and early career physicians are particularly susceptible. We are now launching initiatives to help alleviate physician burnout through the Frigoletto Committee on Physician Well-Being. Dr. Marcela del Carmen, chief medical officer of the physicians organization, has been active in leading efforts to mitigate burnout at Mass General.
Marcela del Carmen: There are data in medicine that the incidence of burnout among physicians is higher when you control for things like age and gender, part-time status, when you compare medicine to other industries, that our job is a little more vulnerable to this burnout, phenomenon.
So for all the right reasons, I think that it's something that we have to tend to and try to figure out a way to support clinicians better.
So a lot of the work that I do is around looking for initiatives to try to mitigate and how do we support doctors better so that they can find meaning and joy in the work that they do every day. And that being one of our primary missions, it's something that I'm pretty vested in.
Amy: A key takeaway from this work has been the increasing demands of modern medicine are unlikely to slow any time soon, so we must stop and face them. And while this task is daunting, we must take it on, for the good of our physicians, for the good of our patients, and for the good of our communities.
This episode concludes season one of Charged. We’ll be taking a break to recharge over the summer so we can bring you more stories of more amazing women in season two. Look for new episodes in your feed this September.
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Thanks for listening and we can’t wait to be back in the fall!
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
Episode #30 of the Charged podcast