A simple equation for health
ADVICE: Quit multiplying by zero to address physician burnout effectively
Mamta Gautam, MD
As I was recently helping my young nephew with his math homework, we discussed the multiplication effect: that any number, no matter how large, when multiplied by zero is still zero. I started to reflect on how this is true in complex human systems as well as mathematical ones. Based on simple multiplication theory, addressing and fixing any “zero” is the only way to have a positive impact on the overall result.
This may be applicable to our efforts in addressing burnout. To date, we have mostly been focusing on some of the relevant factors, such as individual wellness and resilience, while our attention to other crucial aspects, such as systemic issues contributing to burnout, may have been zero.
I have been passionate about promoting the concept of physician health throughout my career. Having personally experienced serious medical illness as a resident, I recognized early that health care does not support the health of its workers.
Since I started working in physician health in the early 1990s, I have been focusing on addressing the individual aspects of physician wellness. This is partly because the person in my psychiatric office asking for help was the individual physician.
Furthermore, the hospitals and medical organizations with whom I was speaking were not yet ready to acknowledge the problems in the system that contribute to burnout. It would be decades before we had scholarly publications and data on the need for physician–organization collaboration in addressing physician burnout.1
In the 1990s and 2000s, medical school deans would agree on the need for healthy medical students, but would remind me of how much other “real medicine” they needed to include in the curriculum. Although the idea of residents being taught about wellness was supported, the specialty colleges had a list of curriculum priorities that, at that time, did not include physician health.
I learned to be persistent and patient. I bring up this topic as often as I can in conversations. I speak about it, teach about it, write about it, research it, consult about it, and create frameworks and programs to address it.
In the past few years, we have been hearing more about burnout than ever before. We’ve learned that one in two physicians is suffering from burnout.2 Burnout is an epidemic hiding in plain sight. Top
I have also seen progress in recognizing the importance of physician health and hope that we are reaching a tipping point. In 2014, Bodenheimer and Sinsky3 recommended the expansion of the Institute for Healthcare Improvement’s Triple Aim (a compass to optimize health system performance, comprising enhancing patient experience, improving population health, and reducing costs) to become the Quadruple Aim, adding the goal of improving physician/provider satisfaction.
In 2015, the Royal College of Physicians and Surgeons of Canada revised the Professional role of the CanMEDS framework to include key competencies of commitment to physician health, collegiality, and support.4
In October 2017, at the World Medical Association meeting, Sam Hazledine successfully lobbied for the modification of The Declaration of Geneva, which is used by physicians across the world and regarded as a modern version of the Hippocratic Oath, to include: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.”5
In 2017, the CMA updated its policy on physician health, recognizing that physician wellness is a key quality indicator and is “attributable to a range of personal, occupational and system-level factors” which must be addressed via deliberate and concerted efforts at a national level.6 The 2018 CMA Code of Ethics and Professionalism, which articulates the ethical and professional commitments and responsibilities of the medical profession, has also specified commitment to self-care and peer support as a fundamental commitment of the medical profession.7
Recently, I have seen colleagues on social media speaking out negatively about the terms “burnout” and “resilience,” urging us to stop focusing on and blaming physicians and, instead, concentrate on improving the system in which we work. They assert that physicians start out healthy; it is the health care system that makes us sick and where the focus needs to be for change.
I completely support the view that the health care system has responsibility for the health of its physicians and that we must start making it accountable for this. We need to address workplace issues such as long hours, frequent call, frustration with administrative burden, paperwork, EMR, feeling undervalued and underpaid, frustrations with referral networks, difficult patients, medicolegal issues, regulatory issues, and insurance concerns. Top
However, we have to be careful not to let the pendulum swing too far the other way and give up all responsibility for our well-being to the system. I feel that we physicians must make sure that we maintain our share of the responsibility for our own health and, therefore, our sense of control. This is not an either/or proposition. I support a model of shared responsibility for physician health, as recently defined in the 2017 CMA Policy on Physician Health.6
One other aspect stands out as impacting physician health: the culture of medicine. The culture in which we work sets high expectations of trainees and physicians, reinforcing perfectionism and self-sacrifice. It teaches us that the patient always comes first; that we should tough it out, keep going without showing weakness or emotion. There is stigma in our culture associated with disclosing an illness and reaching out for help, making us feel that we have failed. Reviewing efforts made in the past 30 years, I see there has been advancement, yet recognize that there is still a long way to go. Top
A simple equation for health
I offer a simple equation to illustrate such a shared responsibility model. Physician health (H) is the product of individual physician factors (I), the culture of medicine (C), and the system/organization (S).
H = I x C x S
Back to simple multiplication theory: if I or C or S is zero, then we are still multiplying by zero and will not have made any progress. We need to ensure that we are working on all of these factors.
Physicians need to continue to learn to recognize and manage their personality traits of being conscientious, perfectionist, highly responsible, and delaying their own gratification. They need to retain a sense of control, set realistic expectations of themselves, and learn to say no. Understanding and ensuring that all of the 5 Cs of physician resilience,8 are addressed and supported is something that we can and must do to contribute individually to our own wellbeing. The 5 Cs are:
We need to continue to address the stigma in the culture of medicine. Speaking about our experiences, sharing our personal stories, and supporting each other with empathy and compassion will go a long way. Top
The system must identify what it needs to address to not overburden physicians, better support their work, and recognize physicians for all that they do. Christina Maslach, creator of the Maslach burnout inventory, describes the six mismatches in the workplace that lead to burnout9: a lack of sense of control, insufficient reward and recognition, lack of community, absence of fairness, conflict in values, and work overload. Health care systems and organizations will need to pay deliberate and concerted attention to each of these six issues and create tangible initiatives to improve and eliminate these mismatches to eliminate burnout.
A complex problem requires complex solutions
Although we are not yet where I envision we can be, we have made a lot of progress in increasing awareness of this issue and reducing the stigma associated with reaching out for help. Ensuring efforts on all aspects of the equation, I, C, and S — the individual physician, the culture of medicine, and the system/organization — is essential in addressing physician burnout effectively and meaningfully promoting physician health (H).
Health care occurs within a complex adaptive system in which elements learn and adapt to changing environments. Understanding and influencing change in our current health care system, such as addressing burnout, requires knowledge of complexity theory and complex adaptive systems.10,11 Health care problems are not simple, such as baking a cake, where there is a recipe that can be easily learned; neither are they complicated, requiring expertise and coordination, such as sending a man to the moon. Instead, they are complex; like raising a child, there is no formula, a high degree of uncertainty, and the potential for unintended consequences.
Physician health is a complex issue. We cannot solve it with a simple, or even a complicated, solution. Successfully addressing physician wellness requires us to modify our approach to appreciate the complexity and interconnectedness of the contributing factors and to design and develop solutions that arise from the continual engagement and adaptation of all stakeholders. With a shared vision of successful outcomes, we can develop guiding principles with minimum specifications or rules. Top
We will need to build relationships, collaborate, increase information flow, allow emergence and experiment with options, identify positive deviance where small groups have come up with creative workable solutions, and accept diversity. This will require open-minded, agile leadership.12 The CSPL white paper13 states that “Efficient and effective reform of Canada’s health care system cannot occur without the active and willing participation and leadership of physicians.” Let’s step up.
1.Swenson S, Kabcenell A, Shanafelt T. Physician–organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience. J Healthc Manag 2016;61(2):105-27.
2.West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018;283(6):516-29. DOI: 10.1111/joim.12752
3.Bodenheimer T, Sinksy C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014;12(6):573-6. Available: https://tinyurl.com/qb5boe3
4.Frank JR, Snell L, Sherbino J. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: https://tinyurl.com/yb8xpbmq
5.Hazledine S. Doctor wellbeing (blog). Sam Hazledine; 2017. Available: https://tinyurl.com/y5yzdhte
6.Physician health. CMA policy. Ottawa: Canadian Medical Association; 2017. Available: https://tinyurl.com/y3fcxf7d
7.CMA code of ethics and professionalism. Ottawa: Canadian Medical Association; 2018. Available: https://tinyurl.com/y68v3bas
8.Gautam M. The 5 Cs of physician resilience. Can J Physician Leadersh 2015;1(3):24-7. Available: https://tinyurl.com/y2f7gbom
9.Maslach C, Leiter M. The truth about burnout: how organizations cause personal stress and what to do about it. San Francisco: Jossey-Bass; 2000.
10.Glouberman S, Zimmerman B. Complicated and complex systems: what would successful reform of medicare look like? Discussion paper 8. Ottawa: Commission on the Future of Health Care in Canada; 2002. Available: https://tinyurl.com/ycz2nqax
11.Zimmerman B, Lindberg C, Plesk P. Edgeware: insights from complexity science for health care leaders. Irving, Tx.: VHA Inc.; 2008.
12.Culture and Leadership Workstream. Culture and leadership: the nine principles of agile leadership. White paper. Ashford, UK: Agile Business Consortium; 2017. Available: https://tinyurl.com/yadkyu9w
13.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. White paper. Ottawa: Canadian Society of Physician Leaders; 2017. Available: https://tinyurl.com/y4t4uepn
Mamta Gautam, MD, MBA, FRCPC, CCPE, is an Ottawa-based psychiatrist who has been working with physicians since 1990. Among her areas of expertise are physician health and physician leadership. Top