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AP Photo/Yves Logghe
Taking a look at doctor burnout.
TRIAGE INTERNAL

A simple strategy helps doctors fight burnout. Could it work for the rest of us?

By Corinne Purtill

In the 1970s, an American psychologist named Herbert Freudenberger was working overtime at both a thriving private practice on New York’s Upper East Side and an addiction clinic in the Bowery. After months of increasing stress and exhaustion, he woke up one morning unable to move from his bed.

Freudenberger examined his symptoms, none of which fit neatly with any pre-existing psychological disorders. The sensation reminded him of the cigarettes his young addicted patients clutched in their therapy sessions, the fire edging dangerously close to their trembling fingertips.

Freudenberger diagnosed himself with the first named case of burnout—a state of exhaustion caused by the excessive demands of the workplace.

Freudenberger’s initial paper described a condition that manifested in physical symptoms like fatigue, headaches, or shortness of breath, and emotional ones like frustration, anger, paranoia, depression, and indifference. The people most susceptible, he argued, were those whose work demanded emotional labor and empathy, placing the “helping professions” (doctors, nurses, social workers, teachers, and the like) most at risk.

Nearly half a century later, Freudenberger’s spark of an idea has ignited a global discussion. On May 28, the World Health Organization included burnout in the most recent revision of its global disease handbook, describing it as a syndrome arising from “chronic workplace stress that has not been successfully managed.”

The high cost for hospitals

No profession is immune to burnout, but modern healthcare seems almost designed to invite it.

Despite little sleep, lots of pressure, mounting regulation, and personal stress, healthcare workers are expected to remain present, alert, and compassionate toward frightened people in emergency situations.

It takes a staggering toll. In the US, physicians die by suicide at twice the rate of the general population. More than half of American doctors say they are physically or emotionally exhausted, and find their work less meaningful than they used to. In turnover and personnel replacement costs alone, a recent study found, burnout costs the US medical system $4.6 billion per year.

Factor in the medical errors caused by exhausted and disengaged physicians, and the cost may be even higher. A 2018 study from Stanford University School of Medicine found that burnout-induced exhaustion caused more medical errors than either unsafe hospital conditions or flawed procedures.

But in a landscape that struggles to find cost-effective solutions to crises, a Boston-based nonprofit has identified a treatment for burnout that’s noninvasive, inexpensive, and has few discernible side effects: getting caregivers together to talk about themselves.

The Schwartz Center for Compassionate Healthcare launched its Schwartz Center Rounds program in 2002. Today, more than 600 hospitals around the world participate in moderated group discussions designed to prevent burnout in hospital workers and boost their compassion for patients and for themselves.

Anyone who interacts with patients can come to their hospital’s Rounds–surgeons, nurses, occupational therapists, the janitors who make sure the floors are clean but not too slippery. The meetings take place in small local hospitals and in giant regional ones, from San Diego to Dublin to Christchurch, New Zealand.

Wherever they are, the structure is the same. Organizers choose a topic: dealing with patients’ families, for example, or a deep dive into a particularly wrenching recent case. A pre-selected panel of volunteers shares their perspective to get the conversation started. Then it opens for discussion.

Moderators gently steer away from efforts to diagnosis or solve problems—no small feat in a room of people who diagnosis and solve all day, every day. The normal hospital hierarchies do not apply. The only thing participants are allowed to do during rounds is talk about how they feel. No judging. No fixing. Just talking.

The meetings are usually at lunchtime, but nobody comes for the food. Lunch at Schwartz Rounds typically involves the kind of bland sandwiches and vending-machine style chips available at workplaces where people tend to eat their meals fast and on their feet, if they get to eat at all.

The point of Schwartz Rounds is to get healthcare workers to do the thing most of them never get to do on the job: take a moment to put themselves first. To think not about what should have been done for a patient in the past or could be done for them in the future, but how a demanding and sometimes punishing job has made them feel.

The hope is that by sharing their own experiences and hearing others do the same, caregivers will come away with more compassion for themselves, and subsequently more energy and space to show compassion and empathy for patients.

“In a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity,” wrote the late Kenneth B. Schwartz, founder of the Schwartz Center for Compassionate Healthcare, where the rounds are the keystone program. “But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient.”

Schwartz Rounds are that pause. The change they make in hospitals offers clues to how to combat burnout elsewhere.

“You can’t take it on yourself”: Rounds at Primary Children’s

Intermountain Primary Children’s Hospital—known more commonly as Primary Children’s—is one of the biggest pediatric hospitals in the United States, serving some 1 million children in a 400,000 square mile coverage area. It’s a Level I trauma center. Extremely ill or injured children are flown to the mountainside campus in Salt Lake City, Utah, from as far away as Alaska.

Working at Primary Children’s means being confronted daily with life at its most unfair and arbitrary. The facility is sparkling clean, with touches that try to soften a hospital’s austerity. There are brightly colored murals and play areas, art and music therapy, and games for hospitalized patients. But it’s still a workplace where roughly 200 children die every year, even when everyone is working their hardest. It’s not a job that’s easily left behind when a shift ends.

Schwartz Rounds started at the hospital in 2014. They take place 10 times a year and draw at least 85 people every time, usually more.

At a Rounds session Quartz At Work was invited to observe in 2018, about 100 people gathered to talk about “non-adherence,” or when a patient or their family is unable or unwilling to follow their physicians’ treatment protocol.

There are many reasons patient families don’t comply with doctors’ instructions: lack of understanding, lack of resources, distrust, negligence. For a health care team that worked hard to heal a child, watching a young patient’s condition deteriorate over subsequent visits for lack of proper follow-up care can be heartbreaking—and infuriating. It’s not hard to see how a caregiver could grow a little colder or a little shorter with every visit, distancing themselves in advance of the awful conversation they see coming, the one where they have to tell a child and their parents that their illness has progressed past the point of help.

“The parents look at us like, ‘You’ve always fixed them.’ And there comes a day where you can’t fix them,” one caregiver said during the Rounds, to understanding nods. “You can’t reverse the irreversible. When they pass away, a piece of us breaks off with them, too.”

There is no talk in Schwartz Rounds about how a hospital worker “should” behave. People talk about the uncomfortable emotions they can’t express to patients: hurt, confusion, rage.

There’s not supposed to be talk of solutions either–no “here’s a study on increasing post-discharge medication compliance”–but people do share their own coping strategies, and their own ways of accepting the reasons people make the choices they do. In medical parlance, patients who resist or don’t follow protocol are often characterized as “difficult.” But what does it mean to be an “easy” parent of a seriously ill child, or an “easy” young person who knows they won’t see adulthood?

One caseworker talked about a conversation with a teenager with a complicated and serious condition about the teen’s refusal to continue treatment. The young person desperately needed someone to hear and recognize their choice. In this case, the caregiver decided, helping meant listening to that patient say what they needed to say, rather than forcing them down a path they didn’t want to travel.

No conversation in this room can change the fact that some families will not do the things they need to keep their child well. But it can move doctors, nurses, and others who have slid too far in one direction on the spectrum between over-involvement and disengagement into a healthier middle place. It can readjust their grip on each case, each patient, so that they can focus when they need to and let them go when they have to.

“You can’t take it on yourself,” a gray-haired doctor says before the group disbands. “You should not assume the burden of every patient—or that’s the road to burnout.”

The human, healing touch

Schwartz Rounds’ namesake is Kenneth B. Schwartz, a Boston-based healthcare attorney diagnosed with Stage IV lung cancer in 1994 at the age of 40.

As a lawyer, Schwartz knew the procedures and protocols that hospitals relied on to keep people alive. As a patient inside that system, he was struck by how deeply he was affected by the unbillable, uncoded acts of kindness caregivers offered on their best days: a squeeze on his shoulder before surgery, getting results back quickly to spare him undue worry, sending a note of encouragement after difficult news.

“For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness,” Schwartz wrote in a 1995 Boston Globe Magazine article that has become a sort of manifesto for the program. “In some ways, these quiet acts of humanity have felt more healing than the high-dose radiation and chemotherapy that hold the hope of a cure.” He died in 1995, days after founding the Boston-based Schwartz Center for Compassionate Healthcare.

Schwartz was a high-powered person humbled by the realities of illness, an experience that gave him additional perspective and empathy for the players in the healthcare system. That leveling is built into the design of the rounds. “It is valuable for a junior doctor to see a senior doctor say, ‘This really upset me,’ or, ‘I f—— up,’” a UK participant said in one study.

Rounds humanizes those who have been put on pedestals, and those whose experiences have been overlooked or ignored. At one hospital Rounds, a member of the translation team spoke up with a plaintive request: If she was being called to tell a family that their child had died, please tell her that information before she walks into the room. A doctor in the room stood to say that he had never thought to do that before—and would never, ever put a translator in that situation again.

It “takes practice”: Rounds at Kaiser San Diego

Kaiser Permanente San Diego Medical Center, a southern California outpost of the national managed care consortium, treats thousands of patients annually. A Schwartz Center Rounds convened last spring focused on a pervasive but rarely acknowledged problem: acts of discrimination by patients against hospital staff.

The first of three panelists to speak was a nurse. Speaking carefully, he told a story of entering a curtained room to care for a patient only to be blocked by a relative who assumed—accurately, in this case—that the nurse was gay.

“Go away,” the man shouted. “You’re filthy. You’re disgusting.” He shoved the nurse out of the curtained cubicle. The patient had a critical emergency. Her family opted to delay her treatment by an extra hour—and risk her life—so that a new nurse could be located.

“My compassion shouldn’t change because of other people’s view of me, but that takes practice,” the nurse said, his voice wavering slightly with emotion.

The stories started to flow. The grotesquely racist patient who hurled bedpans at any caregiver of color who entered his room. The man saved from the brink of death by the hospital’s experienced and diverse staff, who insisted on having only white male doctors as soon as he was well enough to speak.

Another doctor shared that after she was groped by a patient, she found that only people outside the medical profession were truly sympathetic. Her fellow doctors had rationalized away so many similar experiences that they weren’t able to empathize with her own. Later, another woman rose and shared, with a note of surprise in her voice, a sexually abusive thing a patient had done to her. She had never told anyone, she said. There was never a time she felt she could.

People go into medicine usually because they believe in their core that everyone has an equal right to care, the physician, writer, and healthcare executive Atul Gawande said in a 2018 commencement speech at UCLA Medical School. In practice, this is hard. Bigots get sick, as do abusers, and rude people, and people who are generally decent except when they’re afraid and hurting.

“Regarding people as having lives of equal worth means recognizing each as having a common core of humanity,” Gawande said. It is not possible to be open to the fullness of another person’s experience if you are never given the space to face the confusing, painful, and frightening parts of your own.

“Hello, I’m a person, too”

For all the time and money spent trying to figure out how to prevent physician burnout, substance abuse, and suicide, there appears to be transformative power in simply being able to say out loud, “This happened, and it sucked” in a room of people who understand.

Research on the Rounds’ efficacy is limited, but encouraging. An independent 2008 evaluation commissioned by the Schwartz Center found that 84% of US Rounds participants said they felt more compassion for patients and their families as a result of the program, and 90% communicate better with colleagues.

A 2012 study of pilot Rounds introduced at two National Health Service hospitals in the UK found similar support from staff.

“I really appreciated the language. You hear words used you don’t normally hear such as anger, guilt, shame and frustration. They are obviously there, but there is no outlet for them,” one participant said. As another put it: “I was a sceptic and now I am a convert.”

Doctors, nurses, and caregivers have a special role. In literal matters of life and death, they are seen as the gatekeepers to health, to freedom from the hospital, to freedom from pain. It’s an enormous responsibility that comes with great reward on the best days and great challenges on—well, on pretty much all the days.

“The old school way of dealing with it was, ‘We’re the best, we’re tough, we don’t sleep, aren’t we great,’” a doctor at Kaiser said. “But now I think its different. The newer generation is saying, ‘Hello, I’m a person, too.’”

But it is not only those in healing professions who have their empathy tested regularly at work. It is law enforcement, teachers, parents—virtually anyone who is asked to give their time and attention and understanding to other people, again and again, no matter how tiring or long the day has been.

Schwartz Rounds matters not only because most everyone will have an interaction in a hospital as either a patient, a loved one, or a provider, but because compassion is necessary to our basic functioning as humans. It also is a resource that can be both depleted and renewed. To do the latter, people have to be given the space to care for themselves.

It’s not impossible to imagine Schwartz Rounds-like programs working in a variety of professional settings. All it takes is a room, an agreement of confidentiality, and willingness to share and to listen.