Speaking Up for Psychological Safety
As radiologists report increasing levels of burnout, how can we support our colleagues and trainees?
At the ACR Annual Conference on Quality and Safety held in Boston this past September, I had the pleasure of sitting down with Steven J. Swensen, MD, medical director of leadership and organization development at the Mayo Clinic and a senior fellow at the Institute for Health Care Improvement.
While I have known Dr. Swensen to be a champion for radiation protection for many years, I was unaware of his more recent concerns regarding the alarming increase in the rate of physician burnout and decrease in satisfaction with work-life balance among physicians at large, and especially in radiology. Dr. Swensen highlighted for me the escalating frequency of the problem among physicians, relative to the U.S. population at large, and the need to intervene on many levels.
The Mayo Clinic has conducted detailed surveys of physician burnout and satisfaction with work-life balance, both in 2014 and in 2011. The authors concluded that physician burnout and satisfaction with work-life balance worsened over the three-year interval. More than half of U.S. physicians experience professional burnout, with 54 percent of physicians reporting at least one symptom of burnout in 2014 compared to 45 percent in 2011. Similarly, satisfaction with work-life balance also decreased from 48 percent of physicians in 2011 to 41 percent in 2014. Among certain specialties, the results were more alarming, and radiology was no exception. Symptoms of physician burnout were present in 61 percent of surveyed radiologists in 2014 compared to 48 percent in 2011. Satisfaction with work-life balance also dropped substantially among radiologists, from nearly 60 percent in 2011 to less than 50 percent in 2014.
While it is tempting to view this problem as old news, it seems to be getting worse. And the impact on the health care environment overall is substantial and concerning. At a patient level, increased burnout among physicians is detrimental to the quality of patient care, patient safety, and patient satisfaction. For health care workers, increased burnout can lead to profound job dissatisfaction at a minimum and to depression and suicide at a maximum. While many have advocated for promoting personal interventions that promote well-being and resilience, the magnitude of these problems warrants more global interventions directed at the practice environment broadly.
The growing magnitude of this problem has captured the attention of the National Academy of Medicine. One July 7, 2016, the National Academy of Medicine hosted a working meeting that involved leaders from more than 30 professional organizations to examine issues surrounding the clinician resilience and well-being. The intent of this workshop was to assess and understand underlying causes of clinician burnout and suicide and to advance solutions that reverse these trends. In reading about this workshop, I was tempted to fall into complacency about the recurring topic of burnout and suicide, but then I read the discussion papers that were provided for the workshop.
The background material included the tragic story of a young medical student who chose to take her own life on April 11, 2013. In a detailed letter to her parents, this student apologized for hiding the profound depth of her depression from her parents and her friends. While she was unable to explain fully why she did not seek help, it is easy for anyone working in the health care environment to understand how difficult it is to admit personal limitations in a field that demands excellence and perfection every day. Sandeep P. Kishore, MD, PhD, describes this pernicious "culture of silence" that limits health care practitioners from admitting their struggles and seeking help.
This is particularly problematic among doctors in training and junior physicians. Presumably, with advancing age, doctors become more comfortable in their own skin, recognizing their own challenges and accepting them as inherent limitations to their practice. Among junior doctors and doctors in training, seeking help for mental health issues is presumed to lead to decreased opportunities for future employment and to potential challenges in licensure. As most licensing processes require explanations for gaps in training and practice, applications should distinguish between physicians who need time off for mental or physical health reasons vs. those who were removed from a program for work-related reasons. Mental health liaisons who are not directly connected to training programs should also be made available to trainees proactively. So often, trainees are told that resources are available to help them through difficult times, but practical experience suggests significant impediments to availing themselves of these resources — not the least of which are the hours that trainees are often asked to keep and the difficulty in finding time to seek consultation with a mental health expert. Although there are no easy answers for these problems, it is critical that all physicians in a supervisory capacity pay attention to the needs of our young physicians and physicians in training.
Beyond promoting well-being and resilience, health care leaders must focus on improving the practice environment. At the ACR, we are fond of promoting the triple aim for health care popularized by the Institute of Health Care Improvement: improving the individual experience of care, improving the health of populations, and reducing the per capita cost of health care. However, some have advocated adding a fourth aim focused on "improving the experience of providing care." Sikka et al. explain, "The core of work force engagement is the experience of joy and meaning in the work of health care." Here, promoting joy in the workplace is best served by reducing the risk of psychological harm as sometimes occurs when humans work in complex environments such as health care. Specifically, psychological harm occurs from feeling disrespected generally and falling victim to intimidation and bullying. While harsh environments are often excused owing to escalating production pressure and poorly designed workflows, as health care leaders, we must double down on efforts to promote psychological safety at all levels.
"Speak up for safety" is commonly heard in our health care institutions, focused on promoting just culture and non-punitive response to error. Perhaps we should imitate a parallel campaign entitled, "Speak Up for Psychological Safety," in which practitioners are encouraged to speak up whenever they or their colleagues fall victim to disrespectful and bullying behavior. At the Massachusetts General Hospital, we have recently modified our boundaries statement that articulates behavior boundaries that are expected of all of our employees. Germane to this discussion, the MGH Boundaries Statement reads, in part, As a member of the MGH community and in service of our mission, I will never:
• Speak or act disrespectfully toward anyone
• Engage in, tolerate or fail to address abusive, disruptive, discriminatory, or culturally insensitive behaviors.
By establishing such boundaries, we are setting the baseline level of behavioral expectation to ensure psychological safety among our employees and thereby promote a just culture in the workplace. Hopefully, interventions such as these will reduce dissatisfaction with work-life balance, physician burnout, and potentially depression and suicide among health care professionals, including radiologists. We must break the culture of silence that stands between us and effective solutions for these problems that risk the lives of our workforce and plague our profession.
By James A. Brink, MD, FACR, Chair