Speaker 1: Hi and welcome to the show. Subscribe at kevinemd.com slash podcast. Get CME for this episode by clicking on the CME link in the show notes. Today in the show we have Mara Bookbinder. She is a medical anthropologist. Her Kevin Emdy article that she co-wrote is titled What an Occupational Health Lens Reveals About Clinician Burnout. Mara, welcome to the show. Thanks so much for having me. So we'll get into the article in a little bit, but first off briefly share your story and journey.

Speaker 2: Sure. So I'm a medical anthropologist and professor of social medicine at UNC Chapel Hill where I've been a professor for about 14 years. And I've spent the past three years mostly studying issues related to clinician well-being, stress, and burnout. And that sort of led to the article

Speaker 1: that I wrote for Kevin Emdy. All right. So we talk about clinician well-being and burnout a lot on this podcast and on my site at Kevin Emdy. So over the past few years while you've been studying this through your lens as a medical anthropologist, tell us some trends and

Speaker 2: observations that you've been seeing. Sure. So the study that I did was a four-city study of frontline physicians caring for hospitalized COVID patients in Los Angeles, Miami, New York City, and New Orleans. And I was working on that with colleagues at UNC and the Hastings Center in Garrison, New York. And one of the interventions that I think we make in this study that's really important is that we've been hearing a lot about burnout, of course, even before the pandemic, but the pandemic has really amplified a lot of this discussion for obvious reasons. And we have noticed that solutions that tend to get pushed are geared toward things like yoga, mindfulness, things that physicians are encouraged to do to take better care of themselves. And the physicians that we spoke with were really adamant that these strategies are not helpful, that they are sort of victim blaming in a sense, because they are suggesting that if only physicians could sort of do a better job with self-care, they wouldn't have these problems. And what we found in our research is that the sources of these problems really point to kind of underlying structural issues. And so what we've argued in this article is that burnout is not a problem of individual worker distress, it's really a problem of distressed work environments.

Speaker 1: So your article's titled, What an Occupational Health Lens Reveals About Clinician Burnout. So when you talk to some of these clinicians, you mention some of the things that they say, a lot of the self-care tactics that are traditionally used in medical institutions aren't very helpful. Do you have any stories or anecdotes, some quotes that you could use from these clinicians to really articulate the message that they're getting on the ground about clinician

Speaker 2: burnout? Yeah, I mean, they told us repeatedly that the problem is our workload, right? It's not an issue. So a lot of institutions during the pandemic, they tried to address this problem of burnout by providing sessions, lunchtime sessions aimed at self-care, after work sessions, yoga, hypnotherapy, whatever it is. And clinicians repeatedly told us, if you want to make things better for us, hire more staff, pay us more money. We spoke with some newer physicians, sort of younger in their careers in Los Angeles, who were really faced with the decision of, if I test positive for COVID, I am going to have to make a calculated decision about whether I can stay home and safely isolate, or if I will actually have to go into work in an N95 and risk exposing colleagues and patients, because I will not get paid if I don't go to work, and I will not be able to pay my rent and my loans, my student loans for medical school, if I don't work. So those are some of the kind of real structural issues that physicians are facing that are not going to be solved by these self-care strategies, which is not to say that those practices won't help them, but they're not necessarily going to treat the underlying source of these really

Speaker 1: tenacious problems. Whenever I hear about the term occupational health, sometimes I don't automatically equate that to what clinicians do every day. So when you see burnout through an occupational health lens, as you and your co-authors write,

Speaker 2: tell us what exactly do you mean by that? Right, so that's a great point, Kevin, and I think that's part of why we wanted to write this article, because I think that that terminology is not familiar to a lot of physicians, and the field of occupational safety and health is really principally concerned with thinking about work as a social determinant of health. And so, you know, in the same way that during the height of COVID-19, we became all too familiar with workplace exposures for physicians in the form of viral exposure and that sort of thing, we also need to think about some of these psychosocial stressors as exposures that really threaten the health and safety of the health care workforce. And so the occupational health lens, why I think it's so valuable here, is it really retrains our focus from the individual who might be experiencing some of these symptoms of stress and distress to the broader environment that is causing this stress. And so occupational safety and health researchers often use a social ecological framework that really looks at stressors in various levels of the environment, including the immediate organizational context, sort of the broader employment and labor context, and also the societal context that includes social and economic policies that can shape clinician well-being. So I think it's a really useful framework for kind of thinking about how individual health workers are embedded in these much larger systems, and that we have to have a systems way of thinking if we really want to make a dent in clinician burnout, because this has been acknowledged as a problem for a long time. I mean, even before the pandemic, the National Academies of Medicine released a report in 2019 about clinician burnout. And the sources of the problem, I think, are well understood, but we're not really making a dent in the solutions. And so we are hoping that by kind of reframing the way that we think about this problem, we might be able to find different ways

Speaker 1: of going about solving it. Now, from the clinicians that you talked to in your study, what are some, I guess, occupational hazards that they're facing that may be leading to their burnout? What are some specific examples of those? For communication from leadership, that's one of

Speaker 2: the areas that I think that is very actionable. Physicians in our study really appreciated when they had frequent communication from hospital leadership, updating them about policy changes, rationale for those changes. There were some interesting kind of built environment changes that happened during COVID-19 that I think were stressors for physicians. So many spoke to us about how they missed the camaraderie and the opportunities for social interaction with their fellow colleagues because they were being encouraged to leave when they were done seeing patients, to not congregate in social areas of the hospital. Spaces were reconfigured and used in different ways so that there weren't as many staff break rooms as there might have been before. And that really made a difference to kind of some of the joy that physicians felt in coming into work each day because they weren't interacting in the same way. In your article, you talk about

Speaker 1: some interventions that organizations did to help with these occupational issues that lead to clinician burnout. So talk about some of those examples. Sure. So yeah, in the article, we

Speaker 2: actually took some examples that we found in the literature of some small changes that that we think health systems can make that can really make a difference. So one of the things that comes up a lot is frustration with the electronic medical record. And all of the burden, I'm sure that's no surprise to your audience, all of the burdens that come along with keeping up with that documentation. And so there are some large health systems that have been really successful at implementing interventions designed to streamline those processes, eliminate unnecessary documentation, shift some of the responsibility away from physicians onto other supportive roles if possible, and really kind of have physicians be able to be focusing on their time with patients rather than some of these administrative tasks. So I think those are some of the small innovations that we saw coming out of this time period where, you know, there was on the one hand, a remarkable amount of stress and strain on systems, but on the other hand, a really remarkable level of creativity and improvisation for dealing with new challenging conditions and figuring out workarounds for getting around some of these difficult conditions. And I think that we can sort of harness some of what was learned during this period to try to make some more permanent, lasting changes moving forward. Now, you clearly receive the perspective of

Speaker 1: clinicians. Now, through your research, and it could be within the study or outside the study, did you get the perspective of healthcare organizations themselves and how they viewed

Speaker 2: clinician burnout? That is a great question. We did not do that for this study, except to the extent that we interviewed a few physicians who had some kind of administrative role, but that was typically a department chair, a division chief, something like that. We didn't kind of go further up the food chain in terms of hospital management. I think that that is a really important perspective to be included in future studies. I think that those people are harder to reach and harder to engage, obviously, in research because they're very busy. But I think figuring out kind of how to both get their perspectives on what is happening in their institutions, but also to kind of engage them in thinking about progress and change moving forward is really, really important.

Speaker 1: Now, for those healthcare leaders who may be listening to you on this podcast, tell us some of the actionable things that you would suggest that they do to help with these occupational influences that may be leading to clinician burnout.

Speaker 2: Sure. So we released some recommendations coming out of this research. And one of the things that we really urged health system leaders to do is to develop forums for the exchange of feedback between members of hospital leadership and the clinical workforce, the boots on the ground, and really to have those be paid sessions so that clinicians could get time off their duty workstation to be able to engage in these discussions and explain what was happening for them in their day-to-day work lives. One of the complaints that we heard most frequently is that administrative leaders don't really have any sense of what things are like on the wards. And those who saw their C-suite executives actually coming around and touring the wards and seeing what was happening, they really valued that. But I think secondary to that is also the opportunity to have these clinicians give input into policy changes, talk about what's happening for them in patient care, and really foster a two-way dialogue, which I think is even more important than frequent communication because it allows that communication to be bidirectional and to give clinicians an opportunity to share what's on their mind. So that would be one thing that I think would be really, really helpful. Another thing that we found was sort of a lot of frustration with dealing with the fallout of a very broken health care system and particularly around issues of deeply entrenched health inequalities and physicians feeling powerless around the outcomes that patients from vulnerable groups were experiencing. And we found that physicians really carried the weight of sort of dealing with these health inequalities on a daily basis and caring for patients to be very distressing. And so I think that taking these issues seriously and kind of connecting them to the agenda of clinician well-being and clinician burnout is really important because this was another key source that was driving burnout among a very important segment of our sample.

Speaker 1: We're talking to Mara Bookbinder. She is a medical anthropologist. Her KevinMD article that she co-wrote is titled, What an Occupational Health Lens Reveals About Clinician Burnout. So tell us the path forward. What do you expect this lens on physician burnout, what do you expect that to look like in the next few months or so?

Speaker 2: Yeah, I mean, I think that it's important that we think as we start to think about interventions, and that's hopefully where we're leading to coming off of the release of the Surgeon General's National Plan for Health Care Workforce Well-Being last fall. I think we need to think about interventions at multiple levels. And so part of that might be things targeted to individual clinicians, but part of that is also kind of rethinking the workplace and rethinking the work environment. And then also thinking on a higher level about the social and economic policies that are shaping these workplaces and that are shaping the nurse staffing crisis that we are experiencing all over the country right now. So I think that partnering with social scientists and historians who can sort of have this lens on the structural factors that are shaping burnout and well-being at multiple levels within the hospital workplace environment is really crucial. You know, this is not an easy problem. This is probably what we might call a wicked problem, right? Because the causes are so multi-level and they're so deeply entrenched. But there are tools in place already through occupational safety and health research that we can use to, I think, better start assessing workplace environments using scales that are designed to measure organizational culture and incorporate those kinds of measures alongside some of our more standard individual level measures of clinician burnout. And hopefully we can start to kind of chip away at this and think further upstream than just the individual clinician. And my final question, just tell us

Speaker 1: your take-home message that you want to leave with the KevinMD audience. I think my take-home

Speaker 2: message really is just individual physicians, this is not your problem to solve through self-care. This is a much bigger problem that health systems have to take on collaboratively and at levels

Speaker 1: that are much further upstream. Mara, thank you so much for sharing your time and insight and thanks again for coming on the show. Thank you.