Leadership

Combating Clinician Burnout with Community-Building

Article · July 31, 2018

Increasing evidence from medical studies and surveys has erased all doubt about the reality of what’s happening in American medicine today: More than half of doctors are burning out.

The research is sobering. Burnout and isolation are leading to increased staff turnover, more clinical errors, unprecedented levels of depression, and some of the highest rates of suicide and suicidal ideation among any profession in the U.S. — and all this as we approach a shortage of health care professionals, a coming elder boom, and calls to expand the focus of our services to address social determinants of health.

It’s clear we’re facing an epidemic. For many of us in the trenches, our desperate need for relief is driving creative, effective interventions that show tremendous promise in turning the tide. And when we look at these interventions — from leadership models that underscore collaboration to peer-support networks — some of the most impactful solutions share one common feature: community-building.

The Power of Peer Support

A primary care system within the Beth Israel Deaconess Medical Center in Boston provides a laudable example of the value of peer support. With morale at an all-time low among physicians in the network, a small group of providers — led by Nicolas Nguyen, MD — decided to invest in understanding and treating the problem.

Beginning with a baseline evaluation of well-being, physicians in the network’s family medicine practices were surveyed, finding that 78% of providers intended to leave the organization within 5 years — attributed to a range of issues from professional dissatisfaction to feelings of isolation and work compression. Should those numbers play out, that would cost the average clinic, conservatively, over $2.6 million in replacement costs based on internal estimates.

It was clear that the system’s Resiliency Toolkit — a resource guide containing exercises and interventions designed to stem physician exodus — while valuable, was insufficient. Taking lessons from outside the health care industry, and with a $10,000 budget from an administration eager to alter course, a new approach was developed. Through periodic dinners and retreats, and a group email list created to cultivate dialogue among area providers, clinicians soon discovered their colleagues felt just as overwhelmed, isolated, and helpless. In time, case consultations, socialization, and peer support transformed basic camaraderie into meaningful catharsis.

And it wasn’t just about connecting over coffee; it was about connecting over shared values. For the first time, many reported feeling like they had permission to feel — to see themselves and colleagues in the same way they’re taught to see patients: as whole.

When the initiative started, surveys revealed only 22% of respondents had an interest in staying in their practice for 5 or more years. One year and $10,000 later, that number was up to 47%. The intentional construction of community had more than doubled the intended retention rate. Further, the actual attrition rate went from almost 12% annually to closer to 5%.

Even more important to note is that the real shift wasn’t just in behavior — people occasionally coming together. It was a shift in attitude. Once family medicine clinicians saw the value of forming a community, they sought out even more opportunities to engage, evidenced by the fact that attendance at these voluntary gatherings either became stable or increased with every subsequent event. And with the support, modeling, and full participation of leadership, clinicians felt increasingly comfortable being vulnerable and authentically connecting with peers through these gatherings.

How Vulnerability Builds Teams

Inspired by the efforts, a second unofficial experiment began, this time to examine the well-being of the full care team.

An effort was undertaken to assess practices with particularly high levels of staff turnover — some as high as 184% — to glean insight into causality. While a number of possible influencing factors played a role — from procedural requirements to personality dynamics — there was one consistent feature of each of the poorest performing practices: They lacked regular, all-staff meetings. And this absence of meetings is consistent with norms nationwide, the result of a relentless drive for productivity that demands clinics operate at full capacity with little protected time to nurture group dynamics through regular meetings.

Analysis of the turnover data showed that team meetings closely correlated to retention. The more frequent the meeting and more equitable the participation of team members at the meeting, the lower the turnover.

From there, a new intervention was born.

The first Friday of the month, for 1 hour over lunch, the clinic closes its doors and convenes inside a small office, where each member of the team sits in a circle as equals. Following a brief moment of stillness, the dialogue begins with housekeeping items, moving on to acknowledgements, concerns, and shared decision-making among staff and leadership.

And while at any given meeting a receptionist may ask for support managing patient flows or a pharmacist may talk about a new shingles vaccine, there is an expectation of staff and a modeling from leadership that — during that one precious hour of time — each person shows up fully. Conversational equity, eye contact, and other key belonging cues are as present among the team as scrubs and stethoscopes — the subtle indicators that signal to everyone that their ideas, ideals, and contributions matter.

The meetings close with an activity that has yielded perhaps the most profound shift in organizational culture. In an exercise called the Failure Bow, popularized in Schwartz Rounds®, each person stands, shares an error, omission, or challenge from the previous weeks, then leans in and takes a bow. And as team member after team member steps into a space of vulnerability, their colleagues meet them with empathy and compassion — a virtual trust fall.

This single practice site — after 2 years of peer support, connection, trial, and error — has succeeded in bringing the actual retention rate of the full team to more than 93% over the course of the initiative.

These monthly huddles have now evolved into team meetings every 3 weeks, 30–60 minutes in duration. And although other practice sites in the system have implemented slightly differing schedules, all sites maintain a regular cadence and structure, all sites engage leadership as an essential part of the effort, and all sites have been able to sustain the practice with little cost beyond the occasional refreshments. Ongoing evaluation will soon shed light on the retention results of these additional practices, as well.

Much like the previous example of clinician gatherings, the impact of practice meetings has also lasted — not just because of the intervention itself, but because of the culture change it provoked.

The Power of Connection

It’s easy to wonder what’s at work in these examples: What underlying factors are driving the shift in culture? Is it the simple practice of meeting? Is there something in the design and execution of the meeting? What’s the right amount of meeting time? We know that this profound impact cannot be a result of the meetings alone; leaders in primary care practice sites also receive support and training to effectively run those meetings, as well as the leadership development necessary to build better teams. So there’s certainly a trickle-down effect achieved by engaging leadership.

That said, what seems clear, from that original experiment developing networking opportunities to the act of convening the staff, is that community-building is likely playing a role in the solution.

Indeed, we see similar examples of the promise of community-building throughout health care. The Mayo Clinic used peer support groups to help address burnout among thousands of clinicians in their network. They also credit a year-long, institution-wide, community-building effort as the foundation of their system charter, leading to improved staff morale and quality of care.

What’s finally being tapped into — and what there is already extensive data to support — is our evolutionary craving for connection. We’re social creatures, with language, kinship, and tribalism. Recent data makes abundantly clear how needed connection is in our everyday existence and the devastating impact of the lack of community on personal health and wellness, with isolation and loneliness leading to morbidity at rates higher than that of smoking and obesity.

Heretofore, however, solutions to address clinician burnout have been twofold: focused on the system and its untenable pressures, and aimed at the individual and their unique characteristics. In fact, a favorite focus of late is the role that relatively internally focused interventions like mindfulness and meditation can play.

Unfortunately, these approaches fail to get at our core wiring: our biological drive for connection.

As the field of clinician wellness evolves, it’s imperative to focus on the formal and informal ways that human connections can be created and sustained. As evidenced by examples from large health systems like Mayo to a network of primary care sites in Boston, practices as simple as meetings and peer groups can make an immense difference in the daily experience of health professionals. Surely, other interventions aimed at tapping into this underlying phenomenon have yet to be discovered.

At a time of growing commitment to serve the communities that exist outside our system walls, we must concurrently work to develop community within our walls to fashion a real we in order to sustain an amazing army of me’s.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
Michael Dowling and Charles Kenney headshots

Rebooting Health Care: An Optimistic Outlook

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Health Care Organizational Culture Emphasizes Patient Care Only Slightly More Than the Bottom Line

Survey Snapshot: Who Should Lead Culture Change?

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Culture Change Within Health Care Organizations Is Changing for the Better

Leadership Survey: Organizational Culture Is the Key to Better Health Care

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.

Metraux01_pullquote - dinners to combat burnout in the health care community

“Breaking Bread” to Combat Burnout

Can a simple dinner create community among health care providers?

IHI HPMS Visual Management Board Example

The Answer to Culture Change: Everyday Management Tactics

Adoption of a clear rhythm-of-performance measurement and communication via huddles and visual management can affect a culture of staff engagement and continuous value improvement.

ajor Themes from Cleveland Clinic Town Halls 2016

Reigniting the Passion to Practice Through a Multi-Pronged Approach

Cleveland Clinic formed the Practice Innovation and Professional Fulfillment Office to create and sustain an environment that allows clinicians and scientists to thrive through barrier removal, culture change, and support for personal well-being.

Percent in Highest Bracket in Patient Satisfaction Scores - Pre-Post Arm Differences for Hospitalists - Duke Coaching Communication Skills Study

Coach, Don’t Just Teach

The effect of one-on-one communication coaching on clinicians’ communication skills and patients’ satisfaction.

Two-Thirds of Organizations Have a Nurse Leader Career Path

Survey Snapshot: Do Nurse Leaders Need Advanced Degrees?

Though NEJM Catalyst Insights Council members acknowledge a lack of advancement opportunities for nurse leaders, two-thirds of their organizations have a nurse leader career path.

Nurse Leaders and Physician Leaders Should Be Considered Equals in Care Delivery - but Views of Nurses and Non-Nurses Differ

Leadership Survey: Nurses as Leaders: Broad Acceptance, Room to Grow

Nurses are traditionally the backbone of patient care. They form the largest percentage of the health care workforce, far outstripping physicians. But are nurses leaders as well as doers?

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Team Care

104 Articles

Six Modest Proposals for Health Care…

From measuring only what matters with the “give a darn” test to warnings about the…

China’s Health Care: Public Benefit, Enormous…

Though demand for health services in China has outpaced the development of management systems to…

Quality Management

176 Articles

China’s Health Care: Public Benefit, Enormous…

Though demand for health services in China has outpaced the development of management systems to…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now