Chapter 10: Discovering the Severity of Burnout at MD Anderson

Chapter 10: Discovering the Severity of Burnout at MD Anderson

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Description

Dr. Holleman notes that he started at MD Anderson in January 2010, then discusses the severity of the burnout he discovered among the physicians and researchers (also a national problem). He details the sources of burnout among physicians that stem from turbulence in the healthcare environment and at MD Anderson: increased time spent on paperwork, sense of losing autonomy in the clinic, the need for child care, loss of a sense of meaning in the workplace. He notes that no formal studies have been done of faculty scientists, but summarizes findings from an informal survey: increased grant paperwork, shrinking grant funding, drop in morale, conflict with institutional leadership.

Identifier

HollemanWL_02_20170420_C10

Publication Date

4-20-2017

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Overview; Overview; Definitions, Explanations, Translations; MD Anderson Culture; Working Environment; The History of Health Care, Patient Care; On Research and Researchers; Professional Values, Ethics, Purpose; Institutional Mission and Values; Dedication to MD Anderson, to Patients, to Faculty/Staff; This is MD Anderson; Professional Practice; The Professional at Work

Transcript

Tacey A. Rosolowski, PhD:

So tell me about when you came here. And I'd kind of like to get a sense of what you were seeing in the institution, and what—well, let me ask you that first. What kind of temperature were you taking of the institution at the time? The culture for physicians, for researchers? Tell me about that.

Warren L. Holleman, PhD:

Yeah. I came here, I think, in January of 2010. And as has been documented well in the research literature, this was the time that we were beginning to become aware of how serious the physician burnout problem was. And in the years since then, it's become much—even clearer. And it's even worse than we thought. So this current era is a really bad time for physicians in mental health, nationwide. And MD Anderson is no exception. I think the rationale for my position in the first place was that being an oncologist was particularly stressful, because you're dealing with seriously ill patients and death. And that's true. But the real drivers of burnout have now been shown to be primarily other things.

Tacey A. Rosolowski, PhD:

What are the sources?

Warren L. Holleman, PhD:

Well, they have to do with ways that the physician's job has changed in the last 10 to 20 years. The physician work overload is a driver. When I started in this business, our clinic would close at 11:30 in the morning and wouldn't reopen until 1:00. And there was a time in the middle of the day to catch up on paperwork, to meet with colleagues, to go jogging—

Tacey A. Rosolowski, PhD:

Eat lunch.

Warren L. Holleman, PhD:

And believe it or not, they ate lunch. We would eat lunch. We would have noon conferences, discussions. There was a collegiality, camaraderie, teamwork, doctors, nurses, everybody together a lot of times. Nowadays, the typical doctor carries a power bar in their pocket and they munch it between patients. Or if they do stop to eat, it's five minutes, ten minutes, tops. So and along with that work overload, it's the way the job has changed. They used to have a sense of control or autonomy. They used to feel that they kind of ran the clinic, along with the nurses. Nowadays they feel more like employees in a corporation. Somebody else—an administrator runs the clinic, and they're told, "You need to see so many patients per hour," or per shift, or per day, or per week. They have all of these, quote, "productivity quotas," and quote, "targets." These are business terms that have been brought into the medical world that are really foreign to healthcare professionals. Healthcare professionals are motivated to provide quality of care for their patients. And they're being told now that what we really care about is quantity of care. And these values are foreign to our value system, and they—losing control of the clinics, the job overload—these drive burnout. There are other factors as well. Paperwork and, quote, "bureaucracy" have increased. The electronic health record, hopefully it will improve as time goes on. But the average doctor now spends up to 75 percent of their time doing non-clinical work.

Tacey A. Rosolowski, PhD:

Wow.

Warren L. Holleman, PhD:

A lot of that paperwork, electronic health record. So they're only spending 25 percent of the time at the most doing what they really feel called to do. They want to go in the room and talk with the patient, and try to help the patient. And they're being told, one, the administrators are telling them, "You've only got 10 minutes per patient," or, "12 minutes per patient." Secondly, you've got to spend most of that time documenting rather than providing treatment. So that's not very rewarding. And a fourth—so that's a driver of burnout. Another is, burnout seems to be a little higher among young physicians. And the belief there is there are more work-home conflicts. You've got young children. You may be—yeah. That's the primary thing. So institutions that are more attuned to the need for accessible, flexible child care and other services that help young families tend to have lower rates of burnout. And then finally, I would just say that when all of these changes took place over the last few years, the meta effect was a loss of meaning. So instead of going to work, caring for sick and suffering people and trying to provide comfort and pain relief and/or healing, they feel like they're just trying to make money for the institution. So the job becomes more about money than meaning. And that's a driver of burnout. And I would also add that there are really two epidemics right now; physician burnout is the new one. That's the one that's now—as of three years ago, the rate was 54 percent among U.S. physicians. Very carefully studied, and that's an accurate number. And it will be restudied this year. And we'll see if it goes up even more.

Tacey A. Rosolowski, PhD:

Wow.

Warren L. Holleman, PhD:

It's the majority of physicians have an occupational disease, if you can call it that, that impairs their level of—affects their level of energy. They're emotionally exhausted—if they're burned out, by definition, they're emotionally exhausted. And when you're emotionally exhausted, you're also socially exhausted. Are you really connecting with your patients and your colleagues? Or are you just trying to get through the day to get a paycheck? And—

Tacey A. Rosolowski, PhD:

Probably compromises their ability to connect at home and with friends, too. I mean, it's not like the problem lifts when you leave the institution. So they can't—I mean, am I correct here?

Warren L. Holleman, PhD:

Oh, yeah, and—

Tacey A. Rosolowski, PhD:

So you can't recharge.

Warren L. Holleman, PhD:

Right. That's the definition of burnout. You're so tired that when you get out the next morning, your night of sleep hasn't recovered you. So it's going to have a big impact on your family, your own health. But the other epidemic that's really an old one is physician suicide. Physician suicide rates, whereas we have very accurate numbers on burnout—I think suicide is so taboo and hidden that we don't have really accurate numbers. But if you look at causes of death by occupation, for physicians, with most diseases, physicians have the same causes as everybody else. But two things physicians have much higher; one is suicide, and one is, quote, "accidents." And most people think "accidents" are a euphemism for suicide. So physician suicide rate is astronomical. At least 400 physician in the U.S. die of suicide each year.

Tacey A. Rosolowski, PhD:

Wow.

Warren L. Holleman, PhD:

So anyway, but the new kid on the block in the last 10 to 20 years has been the burnout. And so that's a national problem, it's not just MD Anderson. But we have it bad here, too. Then among our faculty scientists, nobody has ever taken the time to study their mental health or their rate of burnout. I did a very kind of brief study, but about the only thing that's ever been done, and found that the morale of scientists, just like the morale of physicians, has dropped pretty dramatically over the past 10 years or so. The drivers there, there are some of the same drivers, and some are different. The elephant in the room is that about 10 or so years ago, the NIH reduced funding for research. I think maybe 10 or 12 years ago, you had three times greater chance of getting a grant application funded than you do now. So now, it's one third what it was just a decade ago. So for faculty scientists whose careers are based on the ability to get grants, that's a dramatic change. And that has everybody worried and scared, and looking for alternative careers. Even some very successful scientists are having trouble getting funding. And the other drivers of low morale that we've found in our study were the paperwork and bureaucracy. Like the physicians, the scientists felt a calling and training and desire to do science, to do research. But they've found themselves spending all their time filling out forms and doing paperwork. To apply for a grant, our institution has dozens of hurdles you have to jump through. Get signatures here, and fill out forms there. Many of the faculty feel that we have a lot more of that than other institutions, and we could streamline that. And there's been an effort to do that. And then the third driver of burnout among the scientists was a conflict with institutional leadership. That, again, is a national trend. All of three of these are national trends. Someone wrote a book that got a lot of attention called, The Fall of the Faculty. And we had the author here at MD Anderson, and his name escapes me. But there's been a tendency over the past decade or so for universities to increase the size of their administration without increasing the size of the faculty. And the scientists, just like the clinicians, feel that they're more employees working for the administrators, rather than being independent scientists and having the administrators there to help the scientists be successful. That's what they said. They said, "In the old days, we felt the administrators were our friends. They were helping us do our job well. Now we feel like they're in our way, and we're having to work for them. Every one of them has a different class we have to attend, or a form we have to fill out." Busy work.

Tacey A. Rosolowski, PhD:

Now, you mentioned when you were speaking about the clinicians that kind of the meta effect of all of these drivers was a basic loss of meaning, and repeated that with respect to the research faculty as well. It strikes me that if meaning is what these individuals are truly after, there's a nice fit between one aspect of the culture of MD Anderson in that, which is that people really understand the mission of the institution and really buy into it. Now, what were you seeing with that when you arrived? What temperature were you taking of kind of the dedication to the mission?

Warren L. Holleman, PhD:

Yeah. That is a great point. I think when I arrived, I saw two almost opposite moods or feelings. On the one hand, I was besieged by unhappy faculty telling me the things I just told you, about all these drivers of low morale. And that just it used to be really fun to work here, and exciting. Now the bad stuff is almost greater than the good stuff. It's not so fun. But at the same time, I've never worked at a place where I saw people more committed to the mission of the institution. And many people have said this, but I'll say it too. From day one—well, first of all, if you've been here, you know this is a really big institution. It's just hard to find your way around. If you stand at the intersection of any place for more than three or four minutes, you'll see someone show up there who's kind of lost. And you'll see some other employee pop in there and say, "May I help you?" And that's just a little thing. But I think that says something about the character of the people who work here and the commitment to the mission. And when I saw even the president of MD Anderson do that, Dr. Mendelsohn [oral history interview], I said—and other executive leaders, that made quite a positive impression on me. But not just them. Any staff, any faculty. It's just part of—almost—I remember going back to my department and saying, "Is this part of the job description to always be giving people directions?" They said, "No, people just do it because they know it's important and it helps."

Tacey A. Rosolowski, PhD:

Yeah.

Warren L. Holleman, PhD:

The other way I saw the dedication to the mission was, some nights we'd have an activity, or I would work late, or I would come in late. For me it was kind of exceptional to be here late, but I would see people who were here routinely late. Typically I would be in the faculty office building, Pickens, and I would see doctors coming back from the clinics, from the hospital, primarily. I would say, "Well, gosh, you must have had a late day." And they'd say, "Well, this is pretty typical." And I'd say, "Oh, well, you're going to get to go home and see your family, I guess, before they get to bed?" "Well, I have a grant due in three days, so I'm going up to my office now to start my research work." And I'd say, "That's dedication." Now, from a work-life balance perspective, I worry about their health. But there's no worry about their dedication to the mission. They're trying to help patients in real time during the day, and then at night they're saying, "I've seen this pattern with my patients. I wonder if I wrote a grant and did this kind of experiment, if this kind of approach might work better than that type of approach." So they're always trying to improve things. That was pretty impressive. And the scientists primarily—the basic scientists are not in this building, so I didn't see that as much. But I know that's very intense work as well.

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Chapter 10: Discovering the Severity of Burnout at MD Anderson

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