COVID-19 has been far from the only source of stress for physicians and other health professionals over the past couple of years. Many have also been affected by inequity in the workplace. That is why leaders at LCMC Health chose to include two questions about equity and its impact on well-being in their AMA Mini-Z Burnout Assessment.
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“One question is, ‘My wellness at work is negatively impacted based upon my race, ethnicity, religion or other identification,’” said AMA member Jay Kaplan, MD, physician consultant and former medical director of care transformation at LCMC Health. “And then the other question is, ‘My wellness at work is negatively impacted based upon my age, gender or sexual orientation.’”
LCMC Health launched the first installment of its burnout survey in 2021, which was distributed to attending physicians, residents, fellows and other health professionals. The survey was repeated in 2022 and expanded to all nurses. While the health system’s data for 2022 is not available yet, the 2021 survey showed that about 46% of the workforce at LCMC Health was experiencing signs of burnout.
In an interview, Dr. Kaplan and Hannah Stiller, MS, well-being program coordinator at LCMC Health, discussed their decision to include questions about equity, how poetry helps, and other initiatives launched to improve well-being.
AMA: Why did you choose to include equity questions in the burnout survey?
Stiller: If you are encountering feeling inequitable in your environment, in situations and in groups, that's going to impact your stress and anxiety. And it's going to ultimately impact your sense of belonging and your purpose in your job.
We needed to know: Do people feel as if they're in an equitable environment? Do they feel respected? And do they feel like they belong in their environment regardless of how they identify in their sex, gender, race, religion, and so on? We'll be continuing to measure that. That's important information that I feed into our chief diversity and social responsibility officer.
AMA: What were some of the responses to the equity questions?
Stiller: We did have some responses of individuals saying that their wellness at work was impacted. It was less than 50% of individuals who felt like their wellness at work was impacted. However, we also didn't hit the recommended 30% response rate.
We have over a thousand responses, but it's still not representative of 30% of our population, so that's difficult to say without hitting that benchmark. I would wager to say that we probably have more folks who would indicate that their wellness at work is impacted.
Dr. Kaplan: It’s also because of the positioning of our health system in New Orleans, where we have the Children's Hospital University Medical Center of New Orleans, both of which take care of a relatively disadvantaged patient population in terms of the social determinants of health. We also have a hospital in New Orleans East, which is an area of New Orleans that still has not completely come back from Katrina.
The social determinants of health play a much greater factor in these areas and diversity, equity and inclusion have been exceedingly important to our health system. That's why we included those survey questions in 2022 as well as 2021.
AMA: How do you determine what to focus on for well-being initiatives?
Stiller: Partially, with some of the feedback from our burnout survey and, partially, it was just simply that I've connected with now probably close to 300 units and service lines throughout our organization within the past year and a half that I've been in this role.
It's just talking to people, listening to what they're struggling with, listening to their frustrations, and just hearing them and understanding that I'm not going to be able to fix the very complicated system that we're in immediately. But I can try to provide them with some tools so that we don't cause additional stress as we move to reorganize how we do things.
Dr. Kaplan: Don’t call me a hero and don’t just tell me that you’re grateful for me. Do something that helps me do my job better. Help me get more people and more assistance. Help me recreate the sense of team that I had before the pandemic came. Help me feel better at the end of my day. The problem is that a lot of senior leaders don’t necessarily know how to go about doing that.
AMA: So, how do you help physicians and other health professionals with those challenges?
Dr. Kaplan: One of the things that Hannah has really used effectively is something we call a pebble-in-the-shoe exercise. I just hiked 96 miles over seven days and at one point I got a tiny little rock in my shoe. After walking about 10 yards, I said to my daughters and to my wife, "I've got to stop. Enough."
Yet, we've asked people to run a marathon with lots of pebbles in their shoes. We haven't said to them, "You can stop and get the pebble out of your shoe." And we've said, "Well, you can't take a day off even if you injured your foot while you were walking."
We've done the exercise where we've asked people, "What's the best part of your day? What's the worst part of your day? And then, “What gets in the way of you feeling really good about your work?" From that place, we'll say to them, "Now we want you to go back to a place where you felt totally fulfilled, where you really felt joy in your work. At the end of your day, you could do a fist pump and say that's why I went into nursing, or that's why I went into medicine, or that's why I'm doing what I'm doing, and you felt that kind of fulfillment. Now, where were you at the time? When did that happen? What did it feel like? Who were you with? What were you thinking about?" Then we say, "From that place where you felt really good about what you were doing, think about what's one thing we could take from there and bring it here to help you bring a little bit more of that here."
Sometimes it's so simple. For example, the respiratory therapists said, “How about suction catheters and distilled water? Just make sure that we're stocked with those.”
AMA: Is the pebble in the shoe similar to the practice of getting rid of stupid stuff?
Stiller: It's very similar. It has the same basis as the getting rid of the stupid stuff toolkit from the AMA STEPS Forward® program. It's basically resilience training in the form of individual empowerment. There are always going to be some things that feel out of our control.
The more and more those things pile up and the more and more frustrated we feel about them, the less and less control we feel over our situation, which contributes to our stress, anxiety and burnout. What things can we pull out of what you are experiencing that we have control over in our environment? When I lead that exercise, I pull directly from AMA that chart, basically, and I ask them to categorize it. Several of them are going to be easy, low hanging fruit, let's-flip-a-switch option, because they're going to be within our department.
Oftentimes when I do this exercise, I will tell them that staffing is not on the table to write down. There's always a bit of a rumble and laughter and frustration underneath that. Then I explain the why behind that because we know that our leaders are actively working on recruitment and retention. Assuming we get the staffing that we need, because we're actively working on it as an organization, what else can we do to help improve your environment while we're working on this very huge, complicated piece?
AMA: We’ve previously profiled an AMA member psychiatrist who uses haiku to contend with pandemic stress. Dr. Kaplan, you also write poetry. Talk about that, and the connection to fighting burnout.
Dr. Kaplan: Poetry is something I've written in my journal since 1970. Although initially I was writing almost every day, most recently I've written only as a way of transforming the feelings that I have. There's no question that we all have a lot of feelings. Everybody—nurses, doctors, all health care workers—have a lot of feelings inside.
I’ve written poetry both during the pandemic and at times when I have been affected particularly by a patient. When I lost a trauma patient who came in, I wrote a poem called “She Knows You Are Coming,” which was about taking care of an elderly gentleman who came into my emergency department.
We've also used my poetry when we've rounded on our staff. I have a poem called “Present Moment.” We'd share that poem and a couple of others with staff as a way of acknowledging and giving them permission to feel.
AMA: While systemic efforts are key for fighting burnout, do you recommend poetry as another outlet?
Dr. Kaplan: What I tell people is that you're going to have these feelings inside, and the real question is how do you transform them? Do you talk with someone about them? Do you cry them out? Do you write them out? Do you dance them out?
Stiller: When I do presentations and rounds with folks, I talk to them about the fact that we all have these feelings. Then I talk with them about the different suggestions that we have to try to help them transform and deal with these feelings in healthy ways, like Dr. Kaplan was saying. Healthy ways of dealing with these feelings are talking about them, going in a room and screaming, going in a room and crying. Those are all so normal to just simply get it out.
Some of the other things that often happen that people use to deal with these feelings are drinking or sleeping or withdrawing, but all that does is numb the feelings. It doesn't make them go away. It's not transforming those feelings, it is just giving us a placeholder for dealing with them in a worse situation in the future. These are things that they talk with their patients about, but it's helpful when they are listening to someone else talking about how to deal with those feelings and that they're in a room with others who have experienced the same thing as others who talk about how they deal with their feelings.