As we near year two of the COVID-19 pandemic, health systems and physicians continue to face added stress and burnout. And now with the Delta-Omicron variant tag team, many health systems are bracing for another surge of COVID-19 cases, which means well-being initiatives may need some revamping. For AMA member Kerri Palamara, MD, that means meeting physicians where they are to determine what their current needs are.
“What we've realized is the second we think we’ve figured it out, things change,” said Dr. Palamara, director of the Center for Physician Well-Being at Massachusetts General Hospital in Boston. “Being open to what we need to do for people has served us well, rather than assuming we know what people need.”
Committed to making physician burnout a thing of the past, the AMA has studied, and is currently addressing issues causing and fueling physician burnout—including time constraints, technology and regulations—to better understand and reduce the challenges physicians face. By focusing on factors causing burnout at the system-level, the AMA assesses an organization’s well-being and offers guidance and targeted solutions to support physician well-being and satisfaction.
In a recent discussion, Dr. Palamara shared how Massachusetts General Hospital continues to adapt their well-being initiatives to better reach physicians across the hospital.
AMA: How have things changed since last year?
Dr. Palamara: Like many other hospitals around the country, we've been dealing with not necessarily high COVID numbers in the hospital, but huge capacity challenges because of all the aftermath of COVID—whether that be people who are still ill, people who delayed care because they were fearful of coming to the hospital, or because their surgeries were canceled. So, we have had a huge capacity and since the spring it's just been worsening.
There's a label called capacity disaster, which is when you have no room in the inn, basically. It’s triggered by several different criteria, but what it means is that we have to get really creative with how we provide urgent care for people to try to avoid sending people to the emergency room. And more recently in Massachusetts, it also means we have to think about what surgeries we are and are not able to do because of emergency orders.
All of this is so stressful. We’ve also seen patient message volume increase. I get a report every month of the number of gateway messages I've received. Pre-pandemic, it was 50 messages a month and now it's about 350. And I’m just one doctor who sees patients part-time, so you think about what that number must look like for full time doctors and then what the nurses are dealing with on the phones. The inpatient side is getting creamed with capacity. The outpatient side is getting creamed with messages. It's just a tremendous amount of stress, and there's all this additional work involved in taking care of people that was never there before, yet pretty much the same staffing structures to do it in. So, people are tired.
AMA: With increased inbox messages, what other challenges are coming up?
Dr. Palamara: Across the board, people are tired. People are working really hard and we're seeing staffing shortages for so many reasons. We're not unlike anywhere else in the country in that we're seeing nursing shortages, we're seeing other service line shortages. We're seeing challenges in supply chain. All the things that other industries are seeing, we have our own version of it in health care.
It's made the jobs of health care really challenging, so we're starting to see people with compassion fatigue. We're starting to see people with more burnout. We're starting to see people struggling with mental health and in ways that perhaps they hadn't before. We continue to have the same types of challenges as before of how do we support our system and how do we support individuals within a system? But it just continues to morph, and we have to be really nimble, looking out and thinking what do people need? How can we take stress off of people's plates?
AMA: Earlier in the year you focused on five steps to address burnout on the front lines of COVID-19 care. How do you know when to shift that focus?
Dr. Palamara: We still use that framework but are taking a more long-term approach and trying to think about how we can get proactive and not just be reactive. And one huge thing that is different is we started a committee. It had been me working for doctors in the department of medicine in my silo. But knowing that there were nursing leaders doing this, employee health was doing this, the employee assistance program [EAP] was doing this, and there were all these different groups of people doing this work throughout the hospital. We needed to get all these people together because we were all talking about this same stuff and not working together. So, we formed this committee called the Workplace Well-being Collaborative with representation across as many role groups as we could account for. We started to think about what we could do to support people and work together to do that. We put all of our resources together into a one stop shop in one intranet site where people could go for everything. We had built one, nursing had built one, EAP had built one, psychiatry had built one. So, we just built one mega site where you could go and still access all those individual ones, but actually get everything that you need in one place. Then we also initiated a going home checklist program and a buddy program across all role groups. We started to think about how we can branch out and start to reach people. It's about starting to work together across different role groups within the organization. Some organizations have been doing this all along, but we weren't. This was a big move for us, and it has really helped elevate the need to continue to support employee well-being to all levels of the hospital.
AMA: What is involved in the going home checklist?
Dr. Palamara: It's a poster that you can print and hang where people check in and check out—in a break room, locker room or hanging in an office. It's a simple poster with six prompts or questions you can ask yourself as you're ending your day. Even if you're working from home, it's still an opportunity to create some space between those two worlds. We have a poster and then we also made badge tags that have different hospital-based resources that people can access if they need it. It walks you through the steps of processing your day, thinking about what went well and really allowing you to embrace that, thinking about what was hard that day, and then letting that go, by starting to shift your presence back to home, thinking about what you might need and how you might ask for help. But also thinking about what help you might be able to offer somebody else.
AMA: It sounds like it also helps to decrease the stigma around seeking help.
Dr. Palamara: There are people who hide and then there are people who might seek mental health. But then there's a wide range in between where peers can be very valuable. We created a spectrum of what peer engagement and interaction can look like, starting from how trained one might be and really expanding it from there. We started a buddy program in April where any employee can be matched up with another employee just to check in with each other—whether that be a text message, phone call or meeting for coffee. We have over 100 employees engaged in that and are about to do another round in the next week. And then we have a peer support program, which is incident triggered like most peer support programs. If you have an event or series of events, you can reach out and connect with a peer who is trained as a peer supporter. We also have several different coaching initiatives—primarily for physicians, but we're working on expanding that to other role groups. That doesn't have to be incident triggered. That can just be because there's something you want to work on, develop or process.
We really tried to engage peers in this process to build community and build enduring resources so that these supporters, buddies, coaches and everything in between can really be a part of giving back to their peers, but also can receive training that's useful in other situations as well.
AMA: Have you measured added stress and burnout levels since starting these programs?
Dr. Palamara: We were doing the AMA Coping with COVID-19 for Caregivers Survey and our last one was in the summer. Then there was a lot of desire in different role groups to do a specific survey for their role group. Since we’ve done a physician-specific survey and a nursing-specific survey as well as an advanced practice provider survey, we can compare and contrast how things are going to what we learned before with the AMA survey.
We’re actually waiting to get some of that data back. Our hope is that in early 2022 we can have some time through this collaborative to sit down with all of our data and say, here’s what we’re hearing. Here are the signals from EAP, here’s what people need and how can we then start to support them?
We weren’t measuring as frequently as we could have been before because everybody was trying to decrease survey burden. But people realize that in order to know how we’re doing, we really do need to track this. What we need to do, though, before just randomly sending out these longer surveys is figure out what we really need to know and how we can capture that on a less intensive basis more often.
AMA: Is there a concern with post-traumatic stress disorders (PTSD) and the pandemic?
Dr. Palamara: There's definitely concern about stress and a lot of the conversations that I've been asked to have with people have been about post-traumatic growth and what can we learn now that can set us up for post-traumatic growth later on?
We're trying to consider how we can get ahead of PTSD and how we can continue to connect people with what makes them be resilient so that can carry them through this time, but also taking lessons from other people as a guide to think about how we as an organization can promote posttraumatic growth.
Something that I'm super interested in and really trying to think about is how to stay creative when people are not feeling very creative right now. And looking for opportunities to connect people with creativity to help transition us into a more positive future. But that is definitely a challenge.
AMA: Will that post-traumatic growth be a focus for you in 2022?
Dr. Palamara: My hope is that we keep going with what we know how to do. As a state, we're pretty well-vaccinated and we're well on our way to having many people being boosted. Hopefully that will help bolster us through these next few weeks.
Then the hope would be yes, that we can start asking about the data that we have. How can we keep working together? How can we move into the future and really set clear goals for ourselves? What will it look like if we're getting through this time well, and how do we work toward those goals? That would be my ideal for 2022.