It is easy to look at the changes required to mitigate burnout and improve compassionate care and see the burden being placed mainly on the physician. Many of the proposed modifications seem to require the one commodity surgeons lack most, time. Any widespread effort to mitigate the burnout crisis must involve decreasing the barriers to patient care and reducing the physicians’ time constraints.
This may seem daunting, but broad changes in our healthcare system have been implemented in the name of quality, reducing errors, and alleviating trainee fatigue. Burnout can be a similar force for change. Much like the resident’s 80-hour workweek, however, in what manner this change is applied will be the ultimate determinant of the movement’s success.
This series of articles dealt with the adverse consequences of surgeon burnout on both clinicians and their patients, and then presented a conceptual framework to promote workforce well-being. Strategies that the SVS might adopt have been suggested. The central proposal is that helping physicians to deliver compassionate, collaborative care will not only mitigate burnout but also will enhance provider engagement, patient experience, and clinical outcomes, as well as improve the quality and safety of healthcare delivery. It seems reasonable to question if such broad strategic proposals are scalable to individual clinical settings.
The characteristics of compassionate care have been well described by patients, and, not surprisingly, only 53% reported that their last encounter with the health care system was compassionate. In 2014, a multidisciplinary consortium published recommendations for advancing compassionate person- and family-centered care. They detailed the attributes, values, and behaviors of such care, including focusing one’s attention, recognizing nonverbal clues, active listening, demonstrating nonjudgmental interest in the whole person, understanding the context of a person’s disease, and asking about the patient’s chief concerns in addition to their chief complaints. Most significantly, the authors outlined how these attributes could be integrated into existing competency documents such as those provided by the Association of American Medical Colleges (AAMC) Entrustable Professional Activities, or the milestones programs of the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM).
It is but a small step to enhance current criteria for certification, clinical appointment, and privileging by including these professional attributes. Bear in mind that these skills are teachable and easily incorporated into health professional education and clinical care. As for metrics, the Schwartz Compassionate Care Scale is a validated patient-rated questionnaire that reliably measures physicians’ compassion and overall patient satisfaction and is available in the public domain. It also provides a metric that is important to clinicians and, when placed on the hospital dashboard, highlights that compassion is an organizational priority. Such priorities become the fabric of the workforce when organizational leadership installs programs such as values-based recruitment, retention, and promotion as Vivian Lee describes at the University of Utah Health System. Mitigating burnout requires changing the culture in which clinicians work and with whom they work.
Vascular surgeons and their professional surgical societies have a leadership opportunity to design high performing teams. Most patient care models have been structured around traditional medical and surgical departments. This paradigm overlooks the fact that patients do not “get sick” within traditional teaching disciplines but do so across varied medical and surgical specialties. Changes in organizational hierarchy are needed so that team-based care is supported. In addition to physician and nurse clinicians, the new teams would do well to expand to all “caregivers,” i.e. everyone who touches the patient (technologists, interpreters, pharmacists, transport workers, support staff, and administrators).
On the front line
On April 15, 2013, at 2:49 pm, two homemade bombs detonated near the finish line of the Boston Marathon killing three people at the scene and injuring 264 others; the most severe sustaining mutilating lower extremity injuries. Much has been written about the preparedness, the emergency response, and the fact that all those who made it to the hospital survived. Jeffrey Kalish, MD, a vascular surgeon at Boston Medical Center and SVS member, was on the front line that day. We asked him to share his personal experience of caring for the victims through the lens of compassionate collaborative care.
“It has been over four years since I went from being a spectator near the Boston Marathon finish line to rushing directly to the operating rooms at Boston Medical Center to help our teams perform lifesaving procedures on critically ill patients, including amputations and complex vascular repairs. While I have learned a tremendous amount since that experience with regard to limb salvage and amputation, reconstructive techniques, and prosthetics, I will focus here on the care the patients and their families received, the lessons our hospital learned from the weeks and months that followed, and how we modeled this care going forward for all amputation patients at Boston Medical Center.
“Based on lessons from the Boston Marathon bombings, I aligned a multidisciplinary team of health care providers in order to formalize and standardize best practices to benefit our amputation patients. STRONG (Surgery To Rehab Ongoing Needs Group) continues to strive toward the ultimate goal of improving and coordinating care for amputation patients and their families as they transition from the hospital setting to rehabilitation. Some of our guiding principles, along with their positive impacts on patient care and physician well-being, are highlighted below:
1. Sustaining hope with a new mindset: Although surgeons have historically considered amputation as a treatment failure, a more appropriate mindset is that amputation can often be a reconstructive procedure in the surgical armamentarium designed to restore a patient back to full function.
2. Seeing the patient in context: Shared decision making can occur more readily once a surgeon and the care team seek to understand the whole person and their family, including what that person does for work and leisure.
3. Communication with colleagues, patients, and families: Patient and family fear and confusion can often be reduced after establishment of a multi-disciplinary team with daily care coordination and consistent messaging. Breaking down traditional hospital silos to allow for improved coordination of care benefits both the patients and the practitioners.
4. Managing emotional and physical suffering: Introducing social workers, mental health professionals, or pastoral care advocates into the care team as soon as a patient is ready can help manage the emotional and psychosocial needs of patients and their families.
5. Sustaining long term surgeon/patient relationships: As clinicians, we can feel rewarded after restoring functional performance in our patients and by meeting the needs of our patients and families. This can occur both in the short-term during the acute hospital stay and in the long-term as we follow our patients’ progress towards achievement of their ultimate goals.
6. Attend to one’s own well-being and foster resilience. There will never be a substitute in our profession for the human connection between our patients and ourselves as their caregivers, and this connection should be one of the most treasured aspects of our work life. We should seek daily reminders of these positive interactions to nurture our ability to cope with a grueling and challenging field, where the outcomes are not always as ideal as we hope.
For me, STRONG is now a consistent and powerful reminder of why I originally became a doctor in the first place, and I strive to propagate this model of compassionate care to benefit future patients as we move forward together.”
We are at an inflexion point in health care. No amount of individual resilience can withstand a toxic or nonsupportive environment. It is unreasonable to think that simply by taking better care of ourselves we are going to resolve the issue of burnout. We need to rethink our current systems of care and focus our energy on developing those that support our ability to deliver the kind of care we know our patients need and deserve. We have an opportunity to alleviate the suffering many providers are experiencing as they strive to heal their patients. We have an opportunity to improve both physician and patient engagement, develop care delivery systems we know our patients deserve, and restore the deep sense of satisfaction that comes from practicing medicine and surgery. There is abundant expertise within our professional medical and surgical societies. The SVS has the courage and the duty to lead.
Drs. Colman, Kalish, and Sheahan extend their thanks and appreciation for the guidance, resources and support of Michael Goldberg, M.D., Scholar in Residence, Schwartz Center for Compassionate Care, Boston, Mass., and Clinical Professor of Orthopedics at Seattle Children’s Hospital.
1. Acad Med (2016) 91:338-344
2. Health Aff (2011) 30:1772-1778
3. Patient Educ Couns (2015) 98:1005-10
4. Acad Med (2016) 91:310-316
7. JAMA (2017) 317: 901-2
8. Clin Orthop Relat Res. (2017) 475:1309-14.