Resiliency on the Job Is Vital for Palliative Care Teams—And for Their Organizations

By Larry Beresford

Despite their holistic orientation to patient care and sensitivity to patients’ and families’ mental health concerns, hospice and palliative professionals are subject to the same hazards of job stress and burnout—as well as the accompanying erosion in quality of life—that afflict other medical specialties. But because the hospice and palliative medicine (HPM) workforce is not large enough to meet demand for its services, protecting this precious resource by helping professionals stay on the job long term is imperative for palliative care teams and departments, as well as for the sponsoring hospitals, health systems, and administrators responsible for the service.

“Recent research shows that our field is not immune to burnout,” said Joseph Rotella, MD MBA HMDC FAAHPM, AAHPM’s chief medical officer. “With a critical workforce shortage in palliative medicine—we can only train so many future clinicians—we need to do everything we can to keep those we have from becoming burned out and leaving the field.”

There is growing recognition that the sources of suffering in HPM are not just the usual healthcare job stresses, but also grief responses to losing patients, Rotella said. “If there is a bad death on the service, it can cause trauma for the whole team. There’s also moral distress when we have strong convictions about what is the right thing to do, but we can’t do it for various reasons.”

Rotella sees a growing national movement to address burnout in medicine. “HPM needs to be part of that movement. We need to look at systemic issues like work flow, being inadequately resourced, a culture of not feeling permitted to ask for help, and not feeling in control of our work. Some organizational leaders are starting to recognize that this is a critically important issue, and that they should invest in retaining their best employees.” Others have taken steps to help HPM professionals manage their job stress and learn techniques of personal resiliency, effective team functioning, and asking for the support they need.

In October 2017, AAHPM dedicated its Ascend Leadership Forum program to the topic of leading and sustaining resilient teams, with an emphasis on teaching individuals how to care for themselves and work with their program leaders to institutionalize support. Rodney O. Tucker, MD MMM FAAHPM, chair in palliative care leadership at the University of Alabama at Birmingham (UAB) helped to convene that forum and said burnout has a definition. It includes depersonalization, cynicism, decreased efficacy, negative self-evaluation, emotional exhaustion, and loss of resiliency. “I’d also say it’s not really a matter of if, but of when, burnout will affect you. You will experience burnout in this work and need to recharge,” he said.

“Some of the issues that have come up consistently for our faculty in general include a lack of available child care, struggles with the electronic health record (EHR), and ‘pajama time’—the number of hours providers spent on their computers away from work, typically at home at night completing charting,” Tucker said. “We’re trying to be more intentional about self-care, such as encouraging fellows to take the day off after taking call.” The palliative care team at UAB dedicates a portion of its monthly meeting to discussion and activities that emphasize self-care.

“In some ways it is a matter of choice—a failure to acknowledge your role in setting boundaries or acknowledging and acting on symptoms of burnout. Institutions can support better work-life balance and provide resources, but they can’t solve (burnout),” Tucker said. “We in palliative care have to find our own acceptable work-life balance and not become palliative care martyrs. We have to master our expectations. I am rearranging my own time commitment in 2018 to have more personal time to pursue outside interests. Sometimes, people need to either cut back their time or shift to doing something else. It might not be the right fit for you.”

How Bad Is Job Stress in Palliative Care?

Arif H. Kamal, MD MBA MHS FAAHPM, and colleagues¹ found through a survey of AAHPM members that burnout is a major issue for palliative care clinicians. More than 60% of the respondents had signs and symptoms of burnout. “As we showed in the Journal of Pain and Symptom Management, burnout is a syndrome that affects all clinicians in palliative care, with higher rates among particular teams, those with fewer than four members, and those with increased on-call responsibilities,” Kamal said.

Emotional exhaustion was identified as a major contributor, but researchers did not observe different rates between palliative care clinicians and hospice clinicians. “We also showed that this issue has started to affect the viability and sustainability of the workforce, as many clinicians are planning to leave the field for issues related to job satisfaction and burnout,” he said.

Christine Sinsky, MD, vice president of professional satisfaction for the American Medical Association, leads development of the STEPS Forward initiative’s practice transformation toolkits, which create an organizational foundation for joy in medicine by helping clinicians and institutions redesign practices to promote physician and patient well-being. She says burnout rates are high across all medical specialties, which has important implications for the quality of patient care, team functionality, and preventing burnout-related turnover. “Consider that it can cost more than $500,000 to replace a physician who leaves the practice because of burnout,” she said.

Sinsky’s research found that one in five physicians intends to reduce clinical workload in the next year and one in 50 intends to leave medicine altogether in the next 2 years.² Burned out physicians show less empathy and make poorer decisions, and patients are less satisfied with the care they receive.

One of the biggest issues in physician job satisfaction and job stress centers on the EHR.

It’s not just the stress and time of inputting data into the computer, but rather how the EHR’s current use compromises personal encounters between physician and patient, Sinsky said. “We do know from various studies of the EHR that how it is designed, implemented, and regulated can be a significant driver of burnout.” It’s not any EHR system in particular, but rather how EHRs had to be designed to meet regulatory requirements and how organizations have chosen to implement their EHR systems, Sinsky said. The goal isn’t for doctors to avoid using the computer, but rather for them to spend the majority of their time in personal encounters with patients.

Some health institutions have taken steps to reduce EHR-related stress, she adds. For example, EHR SWAT teams can be deployed to each unit at the time of implementation of a new medical record to teach doctors how to use the system efficiently and effectively. Designing the interface to reduce the number of computer clicks to get where the doctor needs to go, offering larger screens, and having effective and supportive leadership can all work to make the user more efficient and the process less stressful.

Is It the Individual or the Institution?

“This issue isn’t completely up to the individual. The institution has some responsibility as well,” said Duke Medical School Palliative Care Social Worker Vickie Leff. Ultimately the program is responsible for carving out time for clinical staff to get support. “We promote different varieties of debriefing for our staff and for interns and fellows.”³

As a clinical social worker and member of the interdisciplinary team for the inpatient palliative care consult service at Duke, Leff also provides psychosocial support to other providers. “As palliative care and hospice providers, we’re experts at communication, and we’re pretty good at emotional IQ. Yet we are in the trenches, too, and we need support—some kind of scheduled, structured support,” she said.

“A lot of us in palliative care assume we know how to care for ourselves, but that doesn’t mean we are immune to burnout. We need self-awareness about when we need help. We try to teach that to residents—that it’s OK to ask for help. Don’t wait until you’re crispy,” Leff said. “One of the things we’ve learned that works best is the social support that one gets from one’s colleagues. More than yoga or mindfulness, at the end of the day, it’s about team members supporting each other in settings where you don’t have to explain yourself.”

At UAB, a curriculum has been developed to help the hospital’s four hospice and palliative medicine fellows explore issues of effective work-life balance. The curriculum includes mandatory monthly counseling support and quarterly offsite self-care workshops including museum outings, music therapy, massage, and even a cooking class, all with a focus on encouraging the fellows to explore what it takes to keep them recharged in their work. The fellows also keep journals and write a letter to themselves, to be mailed back to them after they graduate, describing what they have learned about how to manage job stress.

Why haven’t these approaches, developed for fellows, expanded to the whole palliative care service? “We would need everybody in the program and the institution to support it,” said UAB Palliative Care Counselor Kay Knowlton. “One thing experience has taught us is that you can have a wonderful program but the culture of the institution has to be behind it. There has to be willingness to cover for someone who needs time off,” she said. If faculty looks askance any time a fellow asks for time off for self-care, it impacts the fellow’s morale and behavior. “We need to educate people that the way to prevent burnout is good self-care—not just ‘if I have time,’ but to consider it a priority,” Knowlton said.

Finding Work-Life Balance

Vicki A. Jackson, MD MPH FAAHPM, chief of the Division of Palliative Care and Geriatrics at Massachusetts General Hospital in Boston, said many palliative care professionals have not been taught the skills to promote resiliency in their work, in part because of a lack of evidence regarding what works. “As a field, we have not given this issue enough attention,” she said. “When I started here as division chief in 2009, we had many palliative medicine clinicians leave because of burnout,” Jackson said. “The caseload volume was too much. We had to figure out what we could do that would help.”

In an attempt to improve the staff’s control over the workday, a late-start clinician shift was instituted from late morning to early evening, taking all new consults after 2:30 pm, Jackson said. First-year faculty receive an 8-hour curriculum in resiliency training taught by a psychologist who consults with the team to learn a variety of topics for promoting resiliency. These include dealing with one’s own strong emotions, managing unrealistic expectations, and setting appropriate boundaries with patients and colleagues. In year two, clinicians have a one-on-one supervision with the psychologist focusing on strategies for managing job stress. In their third year, they attend a group supervision model to continue this learning. “This is about helping the individual be as effective as they can be on the job,” Jackson said. “My job as leader is to put it in the budget.”

However, there is one critical question that could help to guide future interventions: Is the job stress for the palliative care workforce more so a result of the nature of the work and the stresses of addressing the daily pain and suffering of patients and families facing crises of advanced or life-threatening illness? Or is it mostly the result of administrative chores, demands, and responsibilities such as maintaining the EHR? “These are two important sources of stress for physicians—workload and the content of the work,” Sinsky said.

“In my experience, when the content of the work deals with difficult situations, suffering patients, or grieving families, it gives us a chance to connect with the real meaning and purpose of our work. That’s why we went to medical school in the first place. We get to use all of our skills in those situations to try to lessen suffering, which gives us meaning and nourishes us. This kind of content can be the reason we go to work every day,” she said.

“But if you are used to seeing a certain number of patients per day, with time to sit and talk with each one and listen to their story, and now half of your day is taken up with addressing administrative tasks and paperwork, you will get a lot less of that nourishment,” Sinsky said. “You can’t just keep adding administrative work to our jobs and expect no consequences. That’s why it’s imperative for institutions to structure the team to allow physicians to do the work for which they were trained.”

“There are very concrete steps an organization can take, starting with just being aware of burnout, measuring it with a validated instrument, and understanding the dimensions of burnout in medical professionals,” Sinsky said. “It’s also wise to understand the business case4 for promoting physician well-being. Take steps toward modeling how to create joy in medical practice.”

Rotella represents the Academy on the Council of Medical Specialty Societies (CMSS), which has been discussing the issue of physician burnout, a recognized crisis for all of medicine. “CMSS formed a workgroup to find ways to collaborate with other national stakeholders such as the National Academy of Medicine’s Action Collaborative’s and the American Medical Association’s Joy in Medicine initiative. This has led us to look for other ways that the Academy can support clinicians struggling with these issues,” he said.

“We have found that some nurses, doctors, and other hospice and palliative professionals can do this work for years and years and continue to find joy and meaning in it. In part, that’s because they belong to a community of clinicians and have a place to talk about their work and work through their feelings,” Rotella said. “Does the organization have their back? Is the individual empowered as a professional to do what’s most important for their patients and families and give them what they need? If I can use my professional judgment about what’s right for my patient, I’ll work very hard to achieve it. But it needs to be OK to ask for help and to talk about how they feel about patients who have died and and things that didn’t turn out well.”

Larry Beresford is a freelance medical journalist in Oakland, CA, editor of the Hospice Compliance Letter newsletter published by Weatherbee Resources, and a contributor on end-of-life topics to the Lancet’s United States of Health U.S. blog page. Contact him at This email address is being protected from spambots. You need JavaScript enabled to view it. .

References

Kamal AH, Bull JH, Wolf SP, et al. Prevalence and predictors of burnout among hospice and palliative care clinicians in the US. J Pain Symptom Manage. 2016;51(4):690-696.
Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92(11):1625-1635.
Leff V, Klement A, Galanos A. A successful debrief program for house staff. J Soc Work End Life Palliat Care. 2017;12(2-3):87-90.
Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832.

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