Providing Care Amidst the Physician Shortage
October 22, 2020
Clinical experts talk about the complex causes and solutions to one of healthcare’s biggest issues.
September 24, 2020
The first time Physician Assistant Heather Tonga experienced burnout, she was working long hours at a rural clinic in Washington, and the word “no” wasn’t in her vocabulary.
“I was working all the time, and I also had little kids,” Tonga says. “I was on call a lot. I pretty much didn’t tell people ‘no,’ and I brought work home every day. I was really attached to that clinic.”
When Tonga finally did take some time off for a short trip, the clinic’s managers made some major equipment changes. When she returned and realized what they’d done, she quit.
“It was impulsive. I was really upset that they would do that,” Tonga says.
Even more surprising to her? The clinic accepted her resignation.
“I went through a period where I was depressed and anxious about having quit my job and not meaning to,” she says. “I went to counseling, and I took an anti-depressant for a year. It turns out the clinic actually worked without me. I wasn’t exactly as important as I thought I was. I learned that.”
Through counseling, Tonga says she realized she had been working too much and had become overly invested in her job.
Now, 20 years later, Tonga is a Clinic Medical Director for Providence Medical Group in Oregon. She says she understands herself a lot better and is able to catch burnout before it gets to a breaking point. As COVID-19 stresses even the most resilient clinicians, Tonga is using her hard-earned wisdom to safeguard and protect her staff.
Burnout, according to the World Health Organization, is a syndrome resulting from chronic work-related stress. Research suggests more than 50 percent of clinicians are burned out. The implications of burnout are numerous, from clinician error and low patient satisfaction to poor care quality and decreased healthcare access.
The coronavirus pandemic has only exacerbated the problem. In an August 2020 survey by healthcare research think-tank Larry A. Green Center, four out of five clinicians responded that practice strain is worse now than it was in March 2020.
Provider burnout has some tell-tale symptoms, says Dr. Ryan Dix, a behavioral health manager who has been part of running resiliency programs in Providence Medical Group. Fatigue, disrupted sleep, anxiety and low morale are the most prevalent ones. But burnout also leads clinicians to doubt their abilities, lose the spark they once felt, experience a decreased sense of accomplishment, and have a pessimistic view of the future. In some instances, it can progress into full-blown depression.
The hallmark of burnout is a negative outlook — a cynicism — that often leads to a resistance to going to work, and a hesitancy to engage in work in the way they once did.
“Providers who are burned out have really lost the joy that many of them bring to medicine,” Dr. Dix says. “The great part of our job is being able to help patients and serve patients. Burned out doctors and nurses lose the fire to do that.”
The reasons physician burnout happens are well-studied and documented, and many health systems have implemented programs to address or mitigate its root causes. The common themes of burnout are:
Rules and bureaucracy: Clinicians are surrounded by rules — from the government, insurance companies and hospitals, which limit the time they can spend with a patient.
Overwork: The average U.S. physician works 51 hours a week, with one quarter working more than 60 hours per week, according to the Journal of the American Medical Association.
Computerization: In a recent study, Primary Care physicians reported spending nearly six hours out of an 11.4-hour workday on electronic health records tasks.
Loss of control: Many clinicians wish they had more autonomy and control over their schedules. The coronavirus pandemic has made this worse, with many routines and policies changing almost daily.
Asymmetric rewards: Providers may receive an occasional, small amount of praise from patients and management, but when they make a mistake, consequences are often swift and severe.
Not feeling valued: Particularly during the pandemic, there has been more work, sometimes for less pay, and personal protective equipment shortages.
Outside factors: Home life is usually a refuge for clinicians. When there are stressors in a clinician’s home or community, this can dramatically increase risk.
While solutions to burnout are complex, they do exist, Dr. Dix says.
“Healthcare workers are good at putting their heads down and continuing to do the work,” he says. “The biggest thing the individual provider can do is to look for the symptoms in themselves.”
The next step is to tap into pre-existing coping strategies. The human tendency is to get rid of the extras when life feels stressful, Dr. Dix says, “but the extras are what allow us to keep going. Bring back those basics, whether it’s exercise, sufficient sleep, eating right, reading a great book or talking with a friend.”
If these measures aren’t effective, Dr. Dix says accessing professional help is key, something that can be hard to do for healthcare workers. That’s why systemic interventions are so important, he says, to de-stigmatize physician burnout and make space for people to talk about it.
“Every hospital, region and clinic is different,” he says. “Leadership needs to ask themselves, what approaches will help us? Start with an assessment of what is contributing to the environment of burnout. Do you need to allow providers more control over their schedules? Do you need to look at your workflows? Bring in people to help with your electronic health records? Create opportunities for connection and community?”
COVID-19 has complicated efforts to connect. Coping strategies clinicians depended on pre-pandemic have been significantly impacted. This makes it even more important, he says, for providers to be intentional and creative in finding ways to combat burnout.
Heather Tonga can relate. She says being promoted to Clinic Medical Director just before the pandemic hit has made things tough.
“I’ve felt isolated,” she says. “I haven’t been able to meet with the leadership group. To socially distance, I have an office by myself, and I miss being around everyone.”
Again, just as she did at the start of her career, Tonga is taking stock and rebalancing. She remembers the advice from a physician she worked with when she was younger: to make a list of things that energize you and a list of things that drain you, try to do more of what rejuvenates you and eliminate the drains as much as possible.
She has a big garden, where she spends as much time as possible. She used the Employee assistance program for several counseling sessions to help with anxiety, and she’s picked up running, completing her first virtual 5K by clocking her own time.
She says she has a different perspective now than when she was in her 20s.
“It’s important that we figure out how to take care of ourselves. I’ve been there before, and I don’t want to get burnout again, because I really love the work I do. The last couple of months, I have been paying attention to the signals and getting help.
“My advice to other providers would be, ‘Don’t push through. You’ve got to go home and take care of yourself. Have compassion for yourself.’”
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