Who helps fix the caregivers?

When trauma surgeon Dr. Amy McDonald at Cleveland's MetroHealth has to tell parents their child has died, she wants nothing more than to sit with them, mourn with them and support them.

But then the next trauma victim comes in, and she has to help.

“If I'm at work, and I have a patient die, I can't sit there and grieve,” said McDonald, MetroHealth's director of trauma in the intensive care unit. “I've got to move onto the next patient. What else can I do? You learn to start compartmentalizing.”

A culture of needing to be flawless, invulnerable and strong has left those emotionally draining cases largely undiscussed, tucked away in the corners of caregivers' minds alongside the daily stresses of long hours, paperwork, self-criticism and mounting requirements. The list goes on.

The joy and passion that brought caregivers to the health profession can be cast in the shadow of these stresses.

For decades, there wasn't a space to discuss or deal with these stresses, but in the last several years, the issue is getting what many say is much-needed attention. More surveys and studies are looking into the issue, with many showing doctor burnout topping 50%.

Dr. Adrienne Boissy, chief patient experience officer at the Cleveland Clinic, said burnout comes in three main forms: emotional exhaustion, depersonalization and lack of personal accomplishment.

In his State of the Clinic speech earlier this year, Clinic CEO Dr. Toby Cosgrove highlighted concerns that roughly half of caregivers and physicians reporting unreasonable stress. He said the system is planning town hall meetings to address caregiver stress, which is a “major concern,” not only for the Clinic but across all healthcare delivery.

Northeast Ohio hospitals have programs to help caregivers talk about and manage their stress and systems to identify stressed physicians. They continue to look for ways to reduce stress for caregivers and ensure they are accessing the supports they need.

“If we can give tools to people so they can reclaim their love, their passion, their enthusiasm of being a healthcare provider, then it's phenomenal and everybody will benefit from it,” said Dr. Francoise Adan, medical director for University Hospitals Connor Integrative Medicine Network and its SMART (Stress Management and Resilience Training) program.

The past several years of healthcare reform have exacerbated stress for doctors. Paperwork already was a frustrating, time-consuming task that took providers away from patients. Electronic health record requirements from the Centers for Medicare and Medicaid Services added to that.

Other CMS programs have brought more scrutiny and added pressure for physicians to keep costs down. And doctors are asked to see more patients in less time. Doctors who see more patients per week report higher levels of burnout, according to a national study by TINYpulse, which helps track workplace issues like happiness and engagement. The study, released in March, also found that on a scale of one to 10, healthcare employees rate their work-life balance at 5.87, while all other industries average 7.02.

“Many of us work long hours, and we sacrifice time that we could be spending with our families in order to take care of others,” said Dr. Robert Richardson, elected president of the medical staff at St. Vincent Charity Medical Center, who acts as the physician representative on St. Vincent's board of directors.

To top it all off are the driven personalities the healthcare field often attracts. As a group, physicians are predisposed to burnout, Adan said, noting that many are compulsive perfectionists and can be guilt-ridden.

“The culture of being a physician doesn't emphasize at all taking care of yourself and emphasizes being superwoman or superman,” Adan said. “That all combined really puts them at risk of burnout.”

St. Vincent, like most hospitals, has a system in place to identify burnout. A health and wellness committee at the hospital investigates reports of physician impairment, including substance abuse, emotional problems or stress, Richardson said. The idea is not to punish them, but get them help.

The committee, which gets referrals from colleagues, supervisors or providers themselves, provides advice, support or treatment referrals.

Bob Smith is the director of MetroHealth's medical staff assistance program, which offers a free, confidential, on-site outlet where overwhelmed physicians can feel safe addressing their stress. Smith said when the program began three years ago there were significantly more supervisors referring physicians than self-referrals. In the past 18 months, that has flipped.

Though the portion of MetroHealth's medical staff accessing the program has remained steady, more and more are coming on their own, identifying they need support, which is an encouraging sign, Smith said.

Case Western Reserve University is looking for ways to get ahead of provider stress, said Dr. Steven Ricanati, assistant dean for student affairs at Case's School of Medicine.

He said as a pass/fail curriculum, fewer lectures and small-group, team-based learning helps promote collaboration over competition, which decreases stress. From the beginning, he wants students to understand that medicine is a team sport. When physicians work together, they have more support, give better care and are less likely to experience burnout, Ricanati said.

The school also works to identify stressed or overworked students and get them treatment, like university health services. Ricanati oversees one of the school's academic societies, which puts students into small communities to foster close relationships, which can offer support and help identify students who may be struggling.

And in an effort to prevent getting to that point, the school brings out therapy dogs before exams, offers yoga classes and encourages students to get together for social events. Some may sound silly, Ricanati said, but they are a small but important piece of preparing graduates to be flexible in a time of tremendous change for the healthcare industry.

McDonald, the trauma surgeon, presented at one of the panels that discussed the day the victims of the 2012 shooting at Chardon High School came into MetroHealth.

Years later, it still struck deep and strong emotions among presenters and the hundreds gathered. McDonald spoke about a case few heard of that day. While her colleagues worked to save the high school victims, she dealt with many other traumas, including deaths — in particular a 12-year-old boy who was shot. Despite immediate efforts to save the child, he died.

Since then, she has struggled with the conversation around that day. Everyone — the media, the public, hospital administration — wanted to talk about the Chardon victims and offer support for the emotional toll of that case, but no one asked her about the tragedy of the 12-year-old from Cleveland. “That was upsetting to me,” McDonald said. “Every life should be valued.”

She doesn't want attention for every case. It can become a distraction. And she understands, to an extent, why some make news and others don't. But she grieves for all lives, she said, and had a hard time reconciling the attention and discussion around one over another. This panel gave her a chance to discuss and deal with it.

For about a decade, the Cleveland Clinic has offered emotional support through Code Lavender, a service that sends interventions, such as counseling or spiritual care, to patients and caregivers. In a world where people see death and dying every day, it's a busy service, Boissy said.

Because physicians don't typically show vulnerability, creating a culture that promotes that is key after so many years of not acknowledging there was a problem, Boissy said. Cosgrove focusing on the issue at his State of the Clinic and beginning the town halls are good steps toward changing that culture and facilitating a conversation.

Keeping in touch with your emotions but managing them in a way that lets you remain effective is a difficult, but critical balance to maintain, said Dr. Alfred Connors, chief quality officer at MetroHealth. He recalled a time a medical student got embarrassed when he saw her crying after a family made a difficult decision to not take aggressive actions to revive their father if he died.

“I said, 'Don't be ashamed that you get emotional. This is very difficult,' ” he said. “ 'The day you should worry is when it doesn't bother you.'”

At UH, the eight-week SMART program is a “safe, confidential, non-judgmental, supportive” environment, where providers learn very practical skills — nothing they haven't heard of, Adan said — to build their resilience.

She teaches skills like mindfulness, positivity, gratitude and breathing exercises “to emphasize that it's OK to take care of yourself and to take a few minutes to make yourself part of your priorities,” she said.

Patricia McMullen, nursing supervisor at UH Portage Medical Center, enrolled in the program recognizing that it could help her manage stress in and out of work. The small class afforded her the opportunity to talk about the stress she sees as the afternoon shift supervisor for the whole hospital's nursing staff. She's often stepping in for staffing shortages, helping families cope or responding to code calls, such as cardiac arrests.

Nurses, supervisors, a staffing secretary, a physician and others gave her small group a mix of experiences. The younger participants turned McMullen onto smartphone apps that offer background music for meditation. In turn, she gave them her best stress relief tip: stepping outside for a walk.

The fellowship those group classes offered made her realize she was often isolated during lunch. Now, she eats with people. She breathes deeply a lot at work.

“There was nothing that was really earth-shattering,” she said. “But when you take the hour once a week with a group of people, it's just better.”

MetroHealth offers Schwartz Rounds, a panel of providers and support staff that presents and opens up a discussion to encourage the room to discuss the emotions they deal with on various cases. The tool was developed by the Schwartz Center for Compassionate Healthcare in Boston.

The first at MetroHealth last fall drew 300 people. Since then, they've averaged more than 225 at the monthly program.

Burnout can have clear implications for a provider suffering, including depression, anxiety and substance abuse. There have also been a number of studies talking about the impact of burnout on medical error rates, quality care, safety and patient satisfaction, Boissy said.

The implications could reach further unless the industry tackles burnout. If stress isn't addressed and managed, many worry that doctors will walk away from a profession already facing a shortage.

By 2025, the nation will face a shortage of between 46,000 and 90,000 physicians, according to a 2015 study conducted for the Association of American Medical Colleges. The TINYpulse study found that health care employees who responded are more likely than those in other industries to leave their job for a 10% raise.

And when physicians leave, that means fewer people doing more work, increasing stress and exacerbating the problem.

When McDonald presented to her MetroHealth colleagues about the 12-year-old child who died, she learned of another provider who struggled with the same conflict.

She felt better after having the chance to talk about these shared experiences. Seeing another physician or surgeon dealing with the same emotions, McDonald said, “You realize again: You are not alone. You are not 'weak.'”

"Who helps fix the caregivers?" originally appeared on the website of Crain's Cleveland Business.