Burnout or Moral Injury? Just Let Physicians Be Physicians

As the founder of the Sharp Index, a system designed to predict and prevent physician burnout and suicide, I find that one of my biggest challenges is reducing the “noise to signal” ratio. There are so many ways in which healthcare IT can be improved, and the marketing messages don’t always connect with individual needs. How do you target your healthcare organization’s goals, and how do you determine which tech might reach them?

So, last week I attended American Medical Group Association Annual Conference (AMGA) near Washington, D.C., with a special interest in technology that improves physician experience. I wanted to hear about physician burnout technology solutions and how technology can improve physicians’ work-life balance. I found leadership in physician workflow technology improvement and important conversations about the nature of physician burnout.

Health IT and Physician Burnout

Healthcare marketing campaigns seem overreaching. Many of the messages smack of some tech giant wanting to put its name on a popular problem and rebrand its technology to “THE ONE TRUE ANSWER” — especially when it comes to physician burnout. If there were actually some Lord of the Rings-style, one true technology to rule them all, I doubt that Epic Systems, perhaps the closest to that one ring, would have a parody Twitter account. There is so much talk about healthcare’s need for improvement that, at this point, I wonder whether the pioneers of healthcare technology might need to take a step back and examine whether our current system is relevant to actual health.

One of the themes of AMGA was physician well-being. Zubin Damania, M.D., or “ZDogg,” spoke about “moral injury,” a term developed in the evolving discussions about what burnout should be called. According to his keynote at AMGA and his accompanying video, Damania is “really, really, really tired of people calling it ‘burnout.’ The idea that if 50% of your workforce is unhappy, you can solve the problems with lavender oil and a wellness program is absurd. Physicians have a set of moral objectives — values that underscore their commitment to the profession — and the most significant one is probably the idea of healing. When the systems that are in place within don’t allow for healing, how can they succeed? Irrespective of any critique that physicians have unrealistic expectations, it’s evident that technology is failing to contribute to their job satisfaction in a positive way.”

Moreover, Damania is correct — “victim-shaming” physicians is not constructive. Rather, what gets examined gets improved. At AMGA, I heard about some of the work that technology companies and trade associations are doing to make the incremental and organizational steps necessary for improvement. While faulty technology and moral injury are pieces of the puzzle, it is also important to move forward rather than redirecting or using one part of the problem as an excuse not to improve. Incremental change and the narratives around burnout suggest that most of the efforts in this space have the power to improve the system, to some degree or another. Even if healthcare reimbursement does not allow physicians to give great care, the technology might still be lacking for physicians at the point of care. Faulty reimbursement mechanisms and subpar technology can be problems together and independent of each other.

Improve Physician Well-Being

As leaders such as Damania point out, the system needs more than empathic listening. It seems so broken that even hearing people say “it can be fixed” is getting old. Damania talked about Health 1.0 and 2.0 and 3.0. Does this future thinking hurt progress? Constant revisions seem built in to the system. We are bad at healing the mental health of providers. We need to actively seek technological initiatives that will allow for better outcomes, and AMGA featured some of them.

I saw Robert Groves, M.D., chief medical officer of Banner|Aetna, share what his health system is doing to work with physician joy. In his opinion, we should be careful not to swing between two extremes. On one hand, we are holding health systems accountable for a healthy workplace. On the other hand, Groves finds that every physician has individual power as a healer, and initiatives focused on individual growth should not be abandoned. We should not cut off our foot to spite our leg. According to Groves, calling physician burnout “moral injury” takes some of the power that physicians have to thrive. It is unacceptable to blame people within a broken system for noticing it is broken.

I've seen this article from @inHouseMag "Resident Wellness is a Lie" posted by a lot of folks. It's been shared 20k times. I have some thoughts I'd like to share in response to the article, and really the broader theme 1/ https://t.co/JDTXGlkA4d

— Colleen Farrell, MD (@colleenmfarrell) March 3, 2019

Are the semantics keeping physicians from improving? Physicians are not lazy, and they have the power to thrive despite “moral injury” — with the right support, at least. “Burnout” implies physicians can’t handle the pressure, and “moral injury” implies the system is solely at fault. The message of physician wellness is accurate in that we can all benefit from exercise and health. It is inaccurate in that if you never sleep and must document for four hours outside work each day, you will not be healthy. Seemingly conflicting messages are inevitable in a system trying to simplify a nuanced problem.

My brain:

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

don't say it

Me:

...

But yoga does help. Maybe you're doing it wrong.#physicianburnout

— Sharp Index (@SharpIndex) February 24, 2019

While we are working towards an ideal system, let’s remember to be unafraid of the reality of the world we are in. We should have a healthy workforce, but stating the ideal does not always contribute to improving reality. We all should still go to work in the morning. In a previous LinkedIn post, Grove described what physicians need to improve their work, addressing burnout. Is it moral injury? Are efforts to use mindfulness and technology meaningful?

According to Groves:

We often hear that physicians are “difficult” to manage. Does the phrase “herding cats” sound familiar? First of all, no one likes to be managed, and second, doctors need “managing” least of all if they have the right support. I assert that “managing” physicians is actually the easy part.

Give them:

• Inspiration (you must show by action, that you care about patients and the caregivers)
• Information (easily accessible, comprehensive, timely information on the patient; up-to-date clinical literature; data about the performance of their colleagues in similar situations)
• Incentives (they don’t have to make a fortune, but should be rewarded for their efforts; there’s enough stress in the job without actually being penalized for doing the right thing, as is often the case today)
• Influence (if you get the first three right, then you should also welcome physician input on every aspect of their role and the patient’s care; physicians don’t know everything but should be key drivers of both network and clinical design)

Follow these steps, and the physicians will “manage” themselves. I’m not saying that it’s all easy. But the current focus is wrong. Put effort and resources into objectives that will yield meaningful improvements in physicians’ work life rather than “managing.”

At AMGA, he added another step. The added “I” stood for “interference,” meaning, “Thou shalt not interfere with workflow or productivity,” Groves said. “In other words, don’t make the problem of documentation/measurement worse by requiring more of the team. Instead, bring value that fits the flow and makes the job easier, not harder.”

Groves went on to announce a partnership between Banner|Aetna and Holon Solutions, which he said will improve physician joy. The union “enables Banner Health network providers to access patient records across different electronic health records. This means better care for patients, increased efficiency and a streamlined workflow for clinicians,” according to Groves. Holon solutions is pioneering sensor technology that makes analytics visible.

Physician Burnout or Moral Injury

Leaders in healthcare are challenging physician burnout and the narratives about healthcare improvement. Physicians are not hard to work with. They self-regulate and want to succeed. Technology and leadership provide valuable tools to allow autonomy and power. Damania’s views of moral injury and physician burnout are evolving, and his remarks at AMGA were an invitation to add our voices to the narrative. Electronic health records might not be the source of physician burnout or the cause of moral injury, but improving them is an imperative for attendees of AMGA. Technology and healthcare leaders are working to improve a system, and we are watching the narrative and the solutions evolve. Narratives focused on both burnout and moral injury add value for healthcare leaders and empowered doctors.

Let physicians be physicians.

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