At a recent annual exam for one of us (Walter), the medical assistant had checked heart rate, blood pressure, temperature, and oxygen saturation. Inquiring cheerfully about the Fifth Vital Sign, she flashed the 10-point pain scale of emojis ranging from beaming to grimacing. The only mention-worthy pain was an occasionally aching meniscus from a forgettable high school football career. It was refreshing that she didn’t ask about burnout. Everyone else was. Why not the PCP’s office? It was easy to imagine a frowny-face burnout score triggering the PCP to prescribe resiliency training – yoga, Soul Cycle™, and of course, mindfulness sessions. Déja vu. This trendy to-do about burnout is a reprise of the war on pain a decade ago, in which clinicians were admonished to leave no ache or pain untreated. But that fundamental misunderstanding of pain and its profit-driven treatment created a disastrous opioid epidemic. Nationally, the National Academy of Medicine (NAM) has again weighed in, detailing the costs, patient-safety concerns, and workforce issues. Celebrity speakers offer their patented, packaged solutions. Some measures show burnout scores declining nationwide. Most clinicians have not experienced a drop in distress and suspect that any decrement in scores represents the most troubled individuals’ departure. No one denies the widespread distress among clinicians, its link to a physician suicide rate exceeding even that of military personnel, and its adverse effects at the bedside. But having treated a presumptive diagnosis of burnout for a decade and failed, it is time to rethink the paradigm, to double-check the diagnosis before dispensing more therapy? Recognizing that most clinicians reject the diagnostic label of burnout, Dean and Talbot have refocused the diagnosis away from an individual’s failure to withstand the rigors of a chosen career and reframed the situation as a systemic malady with personal consequences. Moral injury describes a dedicated professional’s predicament caught in an ever-larger, corporatized health care system, who is often asked to compromise that profession’s principles in daily work. Others have labeled these tensions as professional dissonance. Danielle Ofri indicts medicine itself – “It is a betrayal of trust, the trust we gave to our own profession….They are not burned out—they love patient care… they are heartbroken.” With the diagnosis off-target, the therapy is misdirected. Mindfulness programs to remedy clinician burnout are proliferating like pain centers in the early 2000s. Mindfulness and resilience training, often the dual centerpieces of institutional burnout remediation programs, borrow solutions from other industries but fail to recognize the uniqueness of health care—such as clinicians who are significantly more resilient than employees in other industries. In McMindfulness, Ronald Purser postulates that corporations, especially those in tech-intense industries, use mindfulness programs to improve worker performance while distracting them from “the structural problems in the workplace that are causing the epidemic of stress in the first place.” We don’t tell patients with a torn meniscus to take Oxycontin to attain a smiley-face pain scale rating and ski to their heart’s content. Neither should we clinicians accept a prescription to boost one’s endorphins with mindfulness to get through a day full of repetitive trauma. Wading with our patients through the dumpster dive that comprises our EHRs, our neuronal overload is an incessant reminder that our EHRs have earned a grade of “F” from national usability experts. Our families suffer from our workplace wounds, especially as the workload engulfs our nights and weekends. At work or home, the tech-mediated trauma of each visit is compounded by moral injury, as the autonomy, mastery, respect, and fulfillment that define us as clinicians are subordinated to administrative and financial priorities encoded in the EHR and enforced by its 24/7 institutionally sanctioned cyberbullying. At its height, the COVID-19 pandemic revived a sense of common purpose and teamwork among clinicians and administrators. However, as the tidal wave of cases receded and telemedicine remains ascendant, the wounds have reopened, unsolaced by personal contact. The COVID crisis also demonstrated how non-profit health care has become nearly indistinguishable from the for-profit sector, with its relentless cost-cutting, staffing reductions and lavish executive pay, and aggressive bill collection practices towards its traditional core constituency, the poor. Clinicians feel trapped and morally injured daily in a system that forces them to elevate corporate priorities over those of their patients. Unsurprisingly, the business solution to worker distress is the same in both sectors – the numbing nostrums of mindfulness programs. Some leaders in health care quality and safety have acknowledged the need for deep diagnostics and systemic intervention, adding a Fourth Aim on which a health care system should be graded – “improving the work-life of those who deliver care.” So, where to start? Cognizant of the tyranny of metrics that bedevil modern health care, we propose that clinicians and administrators rebuild their teamwork by wielding a mere three questions and one measure. First, the meaningful metric. How much time outside of office hours does the clinician spend on EHR work per week? This “work after work” has recently been highly correlated with burnout measures and readily measured from EHR vendor-programmed reports without custom reports or surveys. Institutional commitment to reducing that number as an executive metric is a start toward meaningful change. And the mini-survey? Administrators should solicit regular feedback on work-life from their clinicians, and vice versa, based on the questions of Paul O’Neill, “Are you treated with respect by everyone that you meet every day? Do you have the tools and support to do your work? Does anyone notice, and thank you?” Such a bidirectional assessment echoes Uber, which iterated its rating system to foster respect between drivers and customers and to improve quality for both. Bringing administrators and clinicians together to improve the results of these pithy measures would be an encouraging start in remedying the root causes of clinician distress. But we can only rehabilitate clinicians, patients, and administrators’ working environment if we first abstain from the narcotic allure of mindfulness prescriptions. Suffering clinicians and their patients deserve solutions, not smiley-face sedation. Walter J. O’Donnell is a pulmonary physician. Wendy Dean is a psychiatrist. Simon G. Talbot is a plastic surgeon. Source
