Getting Back to Medicine as a Community

Interview · July 21, 2016

At Mayo Clinic, COMPASS stands for “Colleagues Meeting to Promote and Sustain Satisfaction.” Initiated by Professor of Medicine Colin West, COMPASS groups are small gatherings of about six to 10 physicians who meet every other week for an hour to discuss issues central to the physician experience.

“There’s a little bit of a structure there to orient people around topics relevant to their experience, relevant to well-being, with an idea of focusing on that meaning driver of burnout,” says West, an internationally recognized leader in professional burnout. “What’s the meaning that we as physicians derive from our work? What are the contributors to that meaning, and what are the things that maybe erode that meaning?”

“The prevalence of burnout was something that we hadn’t necessarily expected, but it began . . . to tell its own story, and it couldn’t be ignored,” notes West about his decision to research burnout. He sat down with NEJM Catalyst’s Steve Swensen to discuss COMPASS groups at Mayo Clinic, physicians’ reactions to these groups, and how they might work in other health care organizations.

“Medicine is a group activity, and we are a community as a profession,” says West. “What we need to do is get back to that community, that engagement, that collegiality where we lean on each other for mutual benefit, which then allows us to take better care of our patients, better care of the health care system.” Read or listen to the interview below.



Stephen Swensen: I’m Dr. Steve Swensen for NEJM Catalyst, [former] Medical Director of Leadership and Organization Development at Mayo Clinic. Today we have a guest whom I’m sure you’ll be delighted to hear from. Dr. Colin West is an MD-PhD Professor of Medicine here at Mayo Clinic. He’s an internationally recognized leader in professional burnout.

Colin, how did you get interested in professional burnout?

Colin West: Well, the story really is just one of, I suppose, luck and good fortune more than anything else. I didn’t have any particular personal driver into burnout experience beyond the usual experiences of anyone going through the medical training process. But my PhD was in biostatistics, and when I was a Chief Medical Resident with that quantitative background, one of my now long-term colleagues, Tait Shanafelt, came to Mayo for his Fellowship, and he was interested in asking questions about physician well-being, distress, burnout.

We connected and decided to initiate a study of internal medicine residents, a longitudinal study which actually continues to this day, and we weren’t sure where that was going to go, but after a couple of years when we started looking at some of the results, the story really started telling itself. And we as investigators, we kept following the data and it became something that we were increasingly interested in, and the prevalence of burnout was something that we hadn’t necessarily expected but began, as I mentioned, to tell its own story, and it couldn’t be ignored.

So one question led to two or three more, which led to an exponential increase in questions. And I suppose like any good research path, we found more work than we could handle individually, and the process just grew from there. So it was a combination of a group with an interest and a passion, and having the right people with exactly the right skillsets to be able to address those questions and hypotheses.

Swensen: Excellent. You brought some robust science to this area that’s very important to our profession, including two randomized control trials with COMPASS groups. So what are COMPASS groups?

West: I’ll maybe step back for just a moment, and as we’ve looked at what some of the contributors or drivers of burnout are, some of them are fairly obvious to people. Work hours, for example. The more hours you work, the more at risk of distress, and burnout in particular, people are. But one of those key drivers is: what’s the meaning that we as physicians derive from our work? What are the contributors to that meaning, and what are the things that maybe erode that meaning?

As we were thinking about designing some interventions to try and promote well-being and reduce burnout, we decided that trying to target that meaning aspect was appealing, and hopefully would be important. So we started thinking about ways that we might help physicians rediscover some of the purpose that they derive from their work. We thought about well, you know, we hear physicians talk a lot about their individual stressors and how they feel isolated and alone in their work, even if they’re in very large group practices, so could we set up some kind of curriculum where we have people work in groups of their peers to explore issues that are central to the physician experience? And some of those would involve sharing how to cope with difficult situations, and some of those may be, how do I maintain joy in my practice? So they can be a mix of both handling the negative from a solution standpoint, and also how do we promote more positive coping strategies for the environments that we’re in?

This led to the development of what we call COMPASS groups, which stands for Colleagues Meeting to Promote and Sustain Satisfaction. And what these trials have involved, the intervention for these studies, has been small groups of six to ten physicians who meet on an every-other-week basis for about an hour, and they get together and have a bit of a curriculum that’s kind of a common thread, a backbone if you will, to their meetings, and they commit to discussing some aspect of that curriculum or a set of topics that they’re supposed to orient around.

But really, another part of their meetings is just reducing that isolation and engaging with their peers and their colleagues. That’s really at heart what the COMPASS groups are: it’s a way to organize groups of physicians to get together, but not in a completely unstructured fashion. There’s a little bit of a structure there to orient people around topics relevant to their experience, relevant to well-being, with an idea of focusing on that meaning driver of burnout.

Swensen: You’ve explained what they are. Why do you think they work? What is the social science, the organizational behavior? What is [it] beyond getting together and discussing some common challenges or joy that you think leads this to being a powerful tactic for, I don’t know what you call it, immunizing against burnout?

West: I think maybe the best way I can answer that question is to share in broad strokes what the participants have told us themselves, and I go back to that sense of isolation that people feel. Even in a very large group practice, people will sometimes feel like: I run in and out of my office, in and out of the patient’s room, over to my hospital service or whatever my roles may be, but I don’t ever really interact with my colleagues in any sort of meaningful way. I might say “hi” in the hallway as I skate by, but we’re all so busy that we’re never really engaging with any of our colleagues.

And that shared experience — and if we think about it in our training processes, you know, in medical school people tend to form fairly close connections, maybe not with their entire class, but with pockets of people — the same thing is true in residency training and so on. And yet in our practices, we get so stretched that sometimes there isn’t attention to that community.

What participants have told us is simply having that time to be with their colleagues, having that be protected and endorsed by the organization, is valuable in and of itself. Now we’ve added a layer to that with the curriculum, because what we want to try to avoid is this notion that you get a group of your buddies together and you gripe about the system for an hour but don’t ever really think about: What’s my role in that? What’s the organization’s role in that? What are some potential solutions, and how do I either activate those for myself or advocate in a more effective fashion? How do I gain insight into my own engagements, and how am I reminded of well, jeez, my colleagues are really amazing, and it’s empowering and engages my own passion to actually visit with them and hear their stories about how they’re dealing with things.

And then in addition, trying to get past this notion that often physicians, maybe as part of this isolation idea, don’t realize that they are by no means the only ones that are dealing with some of these concerns.

And so as we’ve talked with our small group participants over the last few years, they’ve told us, you know, being able to engage with my colleagues, many of whom are people that I otherwise previously had not met, has been remarkably valuable. Orienting around a curriculum that keeps us focused on, how do I deal with maybe some less positive aspects of my work, but also how do I engage positively, how do I learn from what other people are doing, that’s working really well for them? That’s been incredibly powerful.

Knowing that the organization endorses and supports these and values the well-being of the physicians sufficiently to provide this opportunity is something people have commented on. And then, finally, recognizing that in their conversations with their peers, that everyone’s dealing with the same issues. There are variations on the theme, but if someone feels like, well, I’m feeling stretched really thin right now, but boy, everyone else around me seems to be so well put together — I must be the only one who’s not hacking it here, maybe I’m just not cut out for this — that taps into these guilt feelings that physicians often have about not doing enough or not being good enough.

They realize, you know what? Everyone’s struggling to some extent. We can support each other and I don’t need to feel like I am weak or somehow impaired because the stress is problematic. No. Actually I’m just like everyone else. I’m just as good as everyone else, and we need to support and learn from each other.

Those are some of the things that our participants have told us have been incredibly helpful for them, and this may be a good opportunity for me to mention that just about two weeks ago we got feedback from a follow-up survey of a rollout of the COMPASS groups across the organization, and 97 percent of the participants at our institution in these COMPASS groups endorsed that the institution should continue to support these groups and that these were valuable for them as part of their employment, as part of their work experience, as part of their physician experience. So that’s really where the numbers are, people voting when we asked them in anonymous surveys, “Is this important for you? Is this offering a benefit to you?” A massive majority are saying, “Whoa, this is a big deal. Yes, please continue.”

Swensen: Very cool. Camaraderie and the conversations involved is a powerful force, isn’t it?

West: Oh, it is absolutely. And I think medicine is a group activity, and we are a community as a profession. I don’t know that we’ve paid enough attention to that as a profession, and when time gets tight and people feel stretched thin, the default is [that it’s] very easy to simply take care of what’s directly in front of you as an individual and lose sight of this larger community that surrounds all of us.

And the problem with that is, among other things, when we narrow down to just trying to get one foot in front of the other, we know from the burnout literature that even if that feels like what we need to do to survive, we’re actually not helping ourselves optimally take care of our patients, either. So it’s this paradoxical downward spiral of, we think we’re offering self-preservation behaviors, but in fact we may be making the bigger picture worse, when what we need to do is get back to that community, that engagement, that collegiality where we lean on each other for mutual benefit, which then allows us to take better care of our patients, better care of the health care system.

Swensen: Outstanding. So, last question: is this a practical solution for other practices, organizations in the country and beyond? This is solid control, the randomized control trials you did at Mayo Clinic, and [you might] say, “Well, that’s Mayo Clinic. You’re an integrated practice, you’re salaried docs, a different culture.” Is this practical for a small private practice group of family docs or an academic medical center at Harvard?

West: I think one point to note is that the menu of solutions for these burnout and distress issues is diverse, and this is certainly not to suggest that getting groups of physicians together around a curriculum is the only solution to these problems that organizations or practices should consider. But as part of a larger menu, it really is a very feasible, scalable intervention because if you think about what it requires, the organizational practice input is a modest financial investment — paying for someone’s meal. We’re offering 15 or 20 dollars per participant, per meal, which, in the scheme of large budgets or even an individual small group practice budget, is a fairly small amount. We’re not talking about cutting people’s clinical calendars, although that would be wonderful to supplement as an organizational investment. But that doesn’t appear to be necessary for these groups to be successful.

And then the commitment from the individual standpoint is, hey, every couple of weeks can I carve out an hour? Is it over lunch? Maybe my group chooses to have a pre-work breakfast meeting. Maybe we have a Saturday bike route that we go on and we have a picnic lunch where we’re going to dedicate time for this sort of activity. The groups can decide how they want to do this themselves, but that can be adapted to any environment.

I’ve given talks on burnout in general in many different places around the country in the last year or two in particular, and large academic institutions are seeing, well, Mayo can do this. We have a very similar kind of structure at least to our practices, [and] there’s no reason we can’t adopt something similar. But I’ve also had small group practices or even individual practitioners say, “I have a network of people in my home city, let me pick up the phone.” And a month after the talks they’re sending me follow-up emails saying, “Hey, we had our first meeting. This was really cool. I kind of knew these people but this is something that’s really exciting for us.”

So it’s a low-cost option to put on the menu for burnout that has benefits that go, I think, beyond the curriculum. As we’ve touched on, this building of a sense of community when there are a lot of external pressures, that physicians are at least perceiving them as pushing them toward isolation — we can resist that, and it’s healthy for our profession. It may almost be an obligation for our profession, for us to be engaging in this community, because physical well-being issues are prevalent. We have lots of literature to suggest that, and so availing ourselves and taking personal responsibility for engaging in some element of the menu of solutions becomes really a professional obligation to be able to deliver the medical care that we expect of ourselves.

Swensen: Outstanding. Thanks so much. COMPASS groups clearly are an important part of the evidence-based way to address professional burnout, a huge issue in this country. Dr. Colin West, thank you for your time with NEJM Catalyst. This is Steve Swensen at the Mayo Clinic thanking you for your time with us today.

West: Oh, my pleasure to visit with you and to share our conversation with the NEJM audience. Thank you.

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