When it comes to physician burnout, it's important to reduce the stigma associated with help-seeking, in order to improve well-being. Family physician Mark Greenawald, MD, shares his experience and insight on how health systems and physicians can make a difference.
- Mark Greenawald, MD, family physician, Carilion Clinic
- Sara Berg, MS, senior news writer, American Medical Association
- Todd Unger, chief experience officer, American Medical Association
Dr. Greenawald: What we're seeing I think around the country is the Great Resignation. So a lot more people are just saying I'm done with this and that's tragic. And certainly, in many cases, understandable as well. So, what I do think that we're starting to see more of is that help-seeking behavior that people are starting to say, I do need help. And we're starting to create a culture where it's safer to do that.
Unger: That’s Dr. Mark Greenawald, a family physician in Virginia discussing the current state of physician wellbeing in light of the COVID 19 pandemic. Dr. Greenawald believes in changing the negative stigma of “help-seeking” to a more accepting space for physicians to ask for help.
Dr. Greenawald: Even at baseline, the work that we do is very hard and it can take a toll. And how do we make sure that we're supporting each other along the way? So COVID has done nothing but made that toll worse and to cause a lot more of the issues that we struggle with around grief and around death and around suffering, all the things that we physicians are very familiar with but never get used to. And having a peer travel that journey with us, somebody who knows us and knows what our work is like is important.
Unger: He shares his personal experience promoting “help-seeking” in a conversation with AMA Senior News Writer Sara Berg. Here’s Sara.
Berg: Today, I'm talking with Dr. Mark Greenawald about decreasing the stigma for help-seeking and improving physician wellbeing. Thanks so much for being with us, Dr. Greenawald.
Dr. Greenawald: Thank you, Sara. It's a pleasure to be here and I'm really excited that we have the opportunity to talk about this important topic as we enter the new year.
Berg: So before we begin, could you give our audience an introduction to yourself?
Dr. Greenawald: Sure. I'd be glad to. So I am a family physician and I work for Carilion Clinic and at sort of on faculty at the Virginia Tech Carilion School of Medicine. My present position is vice chair for Academic Affairs, Wellbeing and Professional Development, and also serve as the medical director for our Institute of Leadership Effectiveness here at Carilion Clinic.
Berg: Thank you so much. So as we start a new year, it seems like it provides us with a clean slate to do more our work to reduce physician burnout and improve wellbeing. What can we expect in 2022 around wellbeing and burnout?
Dr. Greenawald: 2022, I hope is going to be a big year for this as we really start to come out of the pandemic hopefully. The concern is, of course, as we come out of the pandemic and are finally able to catch our breath again, I think we're going to realize both the direct and collateral damage that have happened over the last two plus years, knowing that we started before the pandemic already not doing particularly well. So I think some things that are going to be really standouts are first of all, staffing is going to a significant issue and finding constructive ways to address staffing is going to be very important in terms of the wellbeing of both clinicians but also care teams.
I think also that what I'm starting to see trends about is maybe this has to do a little bit with the culture that we're seeing right now around people starting to reprioritize in many ways what they want to be doing with their lives. And I think we're going to start to see clinicians, physicians in particular, start to push back a little bit against some of the things that perhaps we've been tolerating for a very long time. And the timing seems right for that as health systems start to figure out how they can create better environments and cultures in order for the practice of medicine to happen. So I think there's going to be less toleration for the dynamic tension that we often experience around quality scores and patient satisfaction. And I think that there'll be more outspokenness in terms of what we need to deal with and what we need to tolerate less of. That's going to be very important.
The other thing is I think more of what we're doing right now, Sara, which is we're going to be talking about it a lot more. And my hope is that that talk becomes a lot more personal, people are going to start sharing, not just general platitudes about what needs to happen, but people are going to start telling more of their own stories about how they have both struggled with just clinician distress and its many forms but then also how they have tried to address it in their own lives, and in many cases, how they've overcome some of those challenges.
Berg: What have we been seeing about some of that physician and care team distress?
Dr. Greenawald: Well, certainly what we've seen is what we're seeing I think around the country first of all is the Great Resignation. So a lot more people are just saying I'm done with this and that's tragic. That's tragic. And certainly, in many cases, understandable as well. So what I do think that we're starting to see more of is that help-seeking behavior that people are starting to say, I do need help. And we're starting to create a culture where it's safer to do that. COVID has already caused significant concerns. And many people are grieving. We've lost. We just lost a teammate last week on one of our care teams. And so, this is real.
And we know people have also been impacted by COVID in terms of their personal lives. I'm not sure that there are very many people anymore who don't know somebody who was close to them or certainly in their social network who hasn't died or been significantly impacted by COVID. And so, I think that we're going to start to see a lot more around that as well. And there's going to be a lot of turnover and a lot of the tension I think is hopefully going to be addressed around things like treatment, immunizations, those types of things, which have caused enormous distress as we know as the pandemic has gone on.
Berg: I'm really sorry to hear about the loss of your teammate. That's never easy.
Dr. Greenawald: No, it's not. And what's interesting about what's happening now with COVID deaths, of course, is that there's a lot of ambivalence about that. We grieve greatly. We have lots of, I've had a few patients in the last few weeks who have died of COVID in the hospital as well. And we grieve that. And yet there's, I think, for many clinicians and certainly care team members a lot of ambivalence because we know the data that many of those folks made choices that we wish they would've done differently around particularly vaccination. And so we're seeing that on our own teams of some of that kind of moral distress that comes from why didn't you make a different decision around this or we wish you had made a different decision around that. And some anger about that. And some anger about what's left behind, in some cases, young families and partners and spouses and extended families. And that's just painful to watch in any situation but certainly when you feel like it could have been prevented.
Berg: Right. Exactly. And is that also where some of that storytelling comes in to be beneficial?
Dr. Greenawald: I think so. I think that storytelling happens on many fronts, Sara. One of the things that I've started to notice over the last, really it has started to happen a little bit before COVID, but I started to notice in some of the journals, we were having leaders who were on their way out. These are physician leaders who were on their way out, they were retiring or had retired from a senior leadership role who were coming out and sharing their story. Their story about perhaps depression that they had lived with throughout their whole career or sometimes other things that had happened that it impacted particularly their emotional or mental health. And I celebrate that on one hand.
And yet what I also worry about in that is that they almost are making a statement that in order to be able to come out and share those things safely, you have to have already reached the pinnacle that you're no longer in a position where that might be a threat to you because, of course, the message is that had they shared that earlier in their career, they were scared to because otherwise they were afraid that it would've impacted their career. And so, the idea that somehow now that's changed, I don't think we're there yet.
And I think it's going to take some folks who are presently in leadership roles, who actually have some skin in the game to start sharing their stories as well. And that's something that I've tried to do regularly when I have the opportunity in my workshops, certainly on podcasts and other things to talk about not my burnout and distress story but stories because there are many. And I think that in doing that and legitimizing that and saying that you can come out on the other side better is going to be really important to make just to change the culture of medicine and to make it more acceptable to say, of course we have challenges and of course we have issues and there are times just like every other human that we take care of where we're going to need to be the help seekers rather than help givers.
Berg: Why is it that medical students, residents and physicians often do struggle in silence?
Dr. Greenawald: Yeah. And I think we've created the culture around that in many ways. I think it starts with the fact that we select out people who are very driven. And that's not necessarily really a bad thing. I think that's how you get through some of the training that we do but then we welcome them into a culture where it's still considered kind of a badge of honor to suck it up. And so I think there's great fear that no one wants to be the one to stand out because they're saying I need help if everybody else is posturing and saying, “Look how strong we are.” And because again, as a student certainly and as a resident, you don't want to be the one who's labeled as the weak one.
And unfortunately, still, I think that there's still too much association with help-seeking as weakness. And so that's where the leadership has to come in and to begin to, again, both model that, legitimize it and also to create space to make it happen. What I see with many residents is what they say is, “I really, I need to get help and I would love to get help but if I reach out for help, somebody's going to have to cover or I'm going to have to do it in secret because nobody can know about it. But my schedule is such that it's hard to even find time to do it.”
And so really beginning to say that seeking help and having support is a team sport. And why should we be surprised when any of us at any point in time given the rigors of the work that we do aren't doing as well? And to be able to support them during that time, knowing that if we're honest with ourselves, our time is probably coming around at some point, I think can help as well. But I think that we do have that hidden curriculum right now where we consider too much a badge of honor, and also the competitive culture, which I think can get in the way as well that nobody wants to be seen as the person who can't make it or is the problem or is weak or sometimes is the contrarian, that they're the one pushing against the dominant culture.
Berg: What are some ways that physicians and health systems and other organizations can change medicine to encourage reaching out and seeking help?
Dr. Greenawald: Culture change doesn't happen overnight. The culture of modern medicine is over a century old. And so, changing that is often painfully slow. And yet it will never change unless we start the process and start to change the conversation. So, I think on organizational levels, certainly on national organizational levels, legitimizing, all we have to do is legitimize the data. The data says that many, many clinicians, in many cases, more than half of clinicians and certain specialties are experiencing significant distress. And so that makes them truly the dominant culture. But unfortunately, it's the very silent dominant culture right now. So being able to talk about it from organizational perspective, to be able to offer resources around that, I think is going to be very important.
Sharing stories, as I talked about before, I think is going to be really helpful for leaders to do that. Some states are taking action now in terms of state medical societies. In our own state of Virginia, we've had challenges with our state medical board in terms of, not the board itself who are very hardworking and I think very caring individuals but the way the laws are structured right now in terms of what has to be reported to the state medical board.
And so recently in Virginia, with the help of our medical society here, a law was passed that basically created what's called a safe haven. And the program is actually called the SafeHaven program, where if physicians seek help through this particular program, unless they are truly a danger to themselves or others, they are protected from having to have that information reported to the state board. And I think it's things like that that really are going to start to allow physicians to overcome. One of the things that they talk about that I hear from colleagues all the time, which is, “If I seek help and it gets reported to the state medical board, it will ruin my career, it could end my career.” And you can understand certainly why people would be very hesitant to seek help if that was the fear that they thought was going to happen on the other side.
Berg: Absolutely. Is that something that other health systems and organizations can do within their state?
Dr. Greenawald: So certainly, I'm very heartened to know that other states have reached out to our medical society here in Virginia to learn exactly about that. And my understanding is there are other states who are going through the same processes right now to begin to try to bring similar laws to bear. All the laws in different states tend to be different. So there's some nuance to that but the model itself has been one that people are very excited about. What's exciting about this particular law is that it doesn't apply just to physicians. It also applies to nurse practitioners. Actually, that doesn't yet apply to nurse practitioners. No, that's not true. It applies to physicians, physician assistants, nurses, nurse practitioners and even some students that it applies to as well. So that's very exciting that this is not just a physician-centric law but it's really looking after the whole care team in terms of making sure that we're providing the opportunity for them to seek help if they should need it.
Berg: That's really great. And it brings it all back it seems to that team-based care, and as long as the entire team is working together and feels good, then that benefits the patient.
Dr. Greenawald: Absolutely. And if anybody on the care team is not doing well, that will impact the care that is provided to any patient. So, you can have the healthiest physicians in the world but if others on the care team are not doing well, we are a team and we are interdependent and that will negatively impact patient care.
Berg: What about individual physicians? What role can they play in decreasing stigma around help-seeking?
Dr. Greenawald: Yeah. First of all, to take every opportunity to care for themselves. And that care is on multiple levels, certainly taking care of themselves physically, making sure they have a physician or other health care provider that is one that is personal for them to take care of their mental and emotional health, to take care of their spiritual health, to take care of their relational health. I think all those things and being very conscious about how they're doing that is important.
And then I think knowing the data that more than half of us at any point in time are likely struggling mightily to be reaching out if they are doing well, to be reaching out to their colleagues and to be checking on them and to say, to literally asking them, “How are you doing?” and not accepting, “I'm fine” as an answer but truly to say, "Look, we're all undergoing a lot of stress right now." And even going to that and that next level question of, so what are you doing to take care of yourself right now? How are you dealing with the stressors that we're under?
And then as I shared earlier, I think it's going to become more and more important that we help to disarm some of the resistance around this by sharing our own stories. And as I shared earlier, I do share my story and I'll share it for our podcast listeners as well, that my first foray into seeking help to the level of professional help came after I had a very tragic obstetrical patient, a mother who died in labor and the baby was neurologically devastated. And it took me an entire year of silent suffering before, basically I'd like to say I had the courage to reach out for help but I wasn't that, it was that my wife finally said, "Enough. You can't continue in the way that you are right now. This is no longer okay."
And so, while I was able to, and we do this well, we physicians can fool people for a really long time to think that we're doing well even as we're not. And I went and saw a licensed professional therapist. And as I tell people, she didn't save my life because fortunately for me, I was never in a position where I thought I needed to take my life as the only answer. But what she did do is she gave me my life back again. And I was able to realize that I lost a year of my life when I was a father of three young children, when I was a husband, when I was trying to take care of a busy medical practice, I lost that year because emotionally, I was not present for most of it.
And so, part of why I'm so passionate about this and why I have devoted so much of my career to this is that I don't want that to happen to anybody else unnecessarily because we know it's happening right now and it's tragic. And so being able to tell our stories and to be able to say, particularly for those, again, who are in leadership positions, who are looked upon as opinion leaders, to be able to say, "It's okay to reach out and seek help."
Berg: That's really powerful. Thank you so much for sharing your story. And I'm sure so many others will find value in that as well. So, we spoke about peer support early in the pandemic as a way for physicians to share their thoughts and struggles. Does peer support play a key role in decreasing the stigma as well?
Dr. Greenawald: Oh, absolutely, Sara, that as you know hasn't changed during the pandemic at all. And I think it has actually just become more urgent in many ways. So, when we think about peer support, I like to even think about it in a more broad sense. Certainly, there's the peer support that I think happens in many hospitals right now, that there's been some things written about it. Sometimes it's called the second victim program or TRUST team, which is what it's called in my own organization but that's about peer support reaching out when something bad has happened. And so, it's kind of a reactive way of peer support. And in that model, there's somebody who is the helper and somebody who is the helped, if you will.
What I have started thinking more and more about is what does peer support look like beyond that? First of all, not just support, but peer encouragement. So rather than just thinking about it as I'm going to reach out when you need help, I'm going to be reaching out all the time and I'm going to be looking for opportunities, not just to help you but to build you up. So hopefully I'm increasing your resistance, if you will, to some of the bad things that can come along, some of the stressors that can come along, along the way.
And as you know, Sara, part of the way I've tried to address that is through a program that was started just before the pandemic two years ago called PeerRxMed, which is a program that basically is a buddy system program that encourages physicians to connect with colleagues as buddies or PeerRxMed partners to travel the journey together. And part of that is each week, I send out a little what I call the buddy check nudge, and just a nudge to say, “Hey, this week, remember to check in,” because one of the things I learned as I started to pilot this program was a lot of physicians intended to reach out to their colleagues and they knew it was important to reach out to their colleagues and to connect with them but they didn't because entropy and busyness just got in the way. And so, by having this nudge, a lot of people say, “That's all it takes is just, oh yeah, I know I wanted to reach out in my case to my buddies, and yet I would've forgotten otherwise.”
And what I encourage in doing that is both certainly helping to support each other in times of struggle, but again, even more so, sharing the professional journey together, which is a challenging journey. Even at baseline, the work that we do is very hard and it can take a toll. And how do we make sure that we're supporting each other along the way? So COVID has done nothing but made that toll worse and to cause a lot more of the issues that we struggle with around grief and around death and around suffering, all the things that we physicians are very familiar with but never get used to. And having a peer travel that journey with us, somebody who knows us and knows what our work is like is important.
And the other part of that, Sara, is making sure, sometimes I would hear colleagues say, "Well, I take that, I talk about that with my wife, or I talk about that with my husband or my partner." And I happen to be married to a physician. And one of the things I realized early on is I didn't want to bring all those things back to her, that that was actually not going to, certainly she wants to support me but always bringing my struggles back was not the vision that I had for our marriage. And so being able to take that to somebody else and to grapple with that with them and bring the fruit of that, which is hopefully some healing back into my relationship was very important for me. And I think others can probably relate to that as well.
Berg: Can you share a specific time when you've seen the positive impact of peer support?
Dr. Greenawald: Oh, absolutely. I can share one from today. I just got off the phone this morning. I have started a new program here at my own organization that, I have to find a catchier name for it, but right now I call it the Professional Fulfillment Project. And what I'm doing with that is looking and trying to have physicians start to think about their career as a developmental progression, rather than just something they're going to be doing for the next X number of years before they retire. So, knowing that they're going to evolve and grow and have different needs at different times in their career and how we can be more proactive about that.
But this morning, I was talking to one of the folks who has been struggling, been struggling a lot in terms of, in this case, her professional career, and has felt incredibly isolated. Part of that is because of her practice situation and part of that is just, again, because of the socialization of we as professionals. And she shared with me that out of the blue, one of her colleagues who just had a sense that something was not right had reached out to her at a time when she, and this was somebody who she knew, so it wasn't just somebody who was a stranger and basically said, "I've been thinking a lot about you. And I know you're newer in practice and I know you're a little bit more isolated and I just wanted you to know I'm thinking about you and I'd love to get together just for some coffee or some tea just to check and see how you're doing."
And I happened to talk to her this morning and this was after this had happened earlier in the day, she was beaming. And again, I know she wasn't doing well previously because I had just received a form from her that showed how much she'd been struggling. And she was just so ecstatic that somebody had thought of her as a colleague and reached out.
So, these are things that can happen every day, they can happen in the hallway just by somebody pausing and saying, "Hey, I've been thinking about you. And I know that you had a really tough patient this week. And if you want to talk about it, please let me know." Or even more proactively, "Hey, let's get together and talk about it and just check in on each other." So those are things that can happen all the time. And the only thing that gets in our way is just our busyness and often just the cultures that we're in, where we just don't do that. And a lot of physicians, unfortunately, even in group practices, function as almost many private corporations running in parallel rather than as a group, a true group practice. And so really beginning to think about how can you change that culture by checking in on each other regularly I think is a really important way that that's not only happening now but will continue to happen more so as we become more intentional about it.
Berg: That's really amazing to hear that someone reached out because sometimes just hearing from someone and feeling heard, it makes so much of a difference.
Dr. Greenawald: Well, and Sara, that gets into this whole idea of we're the helpers, not the helpees. And so, we don't often think about that. And I know and I've participated in the PeerRxMed program and I know that when my buddies reach out to me, I have more than one, how much that means to me every week. And what I found more and more as I'm sharing things with them that I likely would've just brushed under the rug and said, "Ah, it's no big deal." And yet it actually, that was not true. It was a big deal for me but I just felt uncomfortable sharing it. And now, because we've traveled the journey now, some of them for two years checking in every week, it would be unnatural to not share those things. And so that's where the shift happens.
I can't imagine if I was struggling with a, let's say a bad patient outcome this week that was really, really getting to me, I can't imagine me not saying, "Hey, can we jump on a call for 10 minutes? This is just eating me up and I just need to talk to you about him." So that's a huge shift. That's certainly a huge shift for me. I wouldn't have done that two years ago. I would've just gone along in silence and said, "It'll go away eventually."
Berg: You've also spoken about connecting with colleagues before, is this different than peer support? And is it another way to decrease that stigma?
Dr. Greenawald: Yeah. So peer support, I like to think about peer support as kind of concentric circles. And so, in the middle of that circle, peer support is around kind of helping a colleague who's in crisis. So either I recognize, “Oh my gosh, like they're looking really bad. Somebody needs to say something to them, because I'm afraid that something bad will happen if we don't reach out such as they may consider hurting themselves” or something like that. So that's the middle of the circle, kind of the urgent crisis emergency.
And then outside of that is the programs that I referred to earlier that are called second victim programs. Again, ours is called the TRUST program here where we know something bad has happened. And so, we are now trying to say, "Gee, let's at least check on those people to make sure they're doing okay, to acknowledge that this happened and to make sure that they're doing okay." One of the challenges of that, even in my own organization, I work a lot on the ambulatory side and that hasn't translated often to the ambulatory side. And so that's one piece. The other is that often that doesn't translate to litigation issues. So, if somebody has a malpractice issue come up or a board of medicine issue, sometimes those get lost in that process. And so here, we're trying to really start to be proactive about addressing those.
And then in the next layer of that circle. So, if you think outside of that impacting more people is this idea of peer-to-peer support, where you're basically buddying up in different groups, different specialties, or trying to do this in ways of sometimes assigning them. But basically saying, as we say in the PeerRx program, no one should care alone. And so, making sure that you're traveling that journey with a buddy. And that in that circle would also go with having mentors. So having folks who we are looking to, not just mentoring us in terms of our professional career but just in terms of our professional life and then also us reaching out to others as mentors, those coming after us, if you will, and helping to support them as well on the journey, knowing that we just traveled that journey and we know how hard it is. And so, helping them along the way is just the right thing to do.
Berg: So, this has been a really wonderful conversation. And I just want to thank you so much for joining me today, Dr. Greenawald, and talking a little bit more about decreasing stigma around help-seeking.
Dr. Greenawald: Thank you, Sara. It's been a pleasure. And I really hope that some of what we talked about today will be helpful for those who are podcast listeners.
Unger: You can subscribe to Moving Medicine and other great AMA podcasts anywhere you listen to yours or visit ama-assn.org/podcasts. I’m Todd Unger and this is Moving Medicine.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.