The U. S. Surgeon General’s Advisory on Burnout, part 2
The Surgeon General’s advisory addresses what health care organizations should address to reduce the stress and burnout among their workers. In bold letters it declares goal number one: transform workplace culture to empower health workers and be responsive to their voices and their needs. Second, show workers how much they are valued. Third, build a commitment to the health and safety of health workers into the fabric of health organizations. For each of these items the report provides sources and data to support the recommendation.
The advisory also spells out several recommendations they consider the minimum necessary to support a commitment to the health and safety of clinicians. These include establishing a line of responsibility within the senior management structure. Regularly use validated tools to measure stress and intervene when indicated. Encourage staff to take their breaks and time off. Prioritize having adequate personal protective equipment.
Other key recommendations include reviewing internal forms, such as applications, to make sure they don’t deter workers from seeking appropriate mental health and substance use care. All hospitals worry about giving access to controlled substances to persons with substance use disorders and worry about legal jeopardy, so this is harder than it looks like. Likewise, they recommend normalizing conversations about substance use disorders. I remember an episode when I was trying to recruit a physician with expertise in this area and one of the decision makers, a physician, asked why we needed him, since he had no patients in his practice with this issue!
Of course, access to “high-quality, confidential mental health and substance use disorders” is a necessity. My state has a robust advocacy program for physicians and RN’s, but community resources are already strained past capacity. Even when there is an understanding of the need, available resources are likely to be inadequate, given historically poor payment and systematic under-investment in mental health.
This section of the report ends by focusing on two items NOT generally considered, but ones I think are the key to real improvement. First, rebuild community and social connection among health care workers. This is an issue I have addressed repeatedly. But, because teams are both hard to define and their impact is even harder to measure, they are often ignored as managers are further from the bedside or chairside. Lip service may be paid to teams and teamwork, but little else. Second, help health care workers prioritize quality time with their patients and colleagues. Once, some time ago, my hospital was experiencing negative cash flow so an outside “efficiency expert” was hired to do a study. They found that floor nurses were engaged in tasks “only” 71% of the time, so the hospital was clearly overstaffed. Of course, the expert could not account for things like being interrupted by a family member with a concern or a change in a patient’s condition that required prompt assessment. Conversations among staff were presumed to be gossip at worst or socializing at best. Yet team building requires such interactions.
In 2018 Houston Methodist began a program to improve its resilience using three specific initiatives: positive psychology, mindfulness, and “comfort rounds.” They believe this initiative helped both staff and the organization cope with the stress of the pandemic. They also found the effort did make staff feel they were being supported by the organization, which is a goal recommended in the advisory report.
As encouraging as this report is, I think we miss the mark if we fail to recognize that the pandemic was not just “more of the same.” Health care work has always been stressful, physically and emotionally, but the pandemic was associated with real mortality risk to clinicians, particularly in the early days. I think this fact means we should think of this as the equivalent of war, not just a surge in patients. I think many (former) staff have the equivalent of battle fatigue or combat stress reaction.
So, what have we learned from the military about battle fatigue? A report from the RAND corporation summarizes what is known about minimizing the psychological and operational damage caused by combat. Quoting Army Manual FM 6-22.5, “Combat Stress,” they note:
“Any service member who shows persistent, progressive behavior that deviates from his baseline behavior may be demonstrating the early warning signs and symptoms of combat stress reaction. Trying to memorize every possible sign and symptom is less useful than to keep one simple rule in mind: Know your troops, and be alert for any sudden, persistent or progressive change in their behavior that threatens the function and safety of the unit…
In general, soldiers and marines should be treated at the least restrictive level and in the greatest proximity to the original unit as both the tactical situation and the symptom severity warrant…
Treatment should be provided as soon after evacuation as possible, and casualties are told by an authoritative source that they are expected to recover and return to their units…”
In other words, the persons suffering a stress reaction is reassured that theirs is a normal reaction to an abnormal situation and that with sleep and food, the proverbial “three hots and a cot,” they will be able to rejoin their units and function with their comrades. To my way of thinking, what this experience shows is that health care organizations need to invest a lot more effort in selecting and training small unit leaders and building on comradery.
I recognize we are in a time of “bowling alone,” “working from home,” and other trends that result in a general stretching of the social bonds that hold our communities together. This means organizations must be intentional about creating healthy communities within the walls if they want to create healthy communities outside the walls.
14 August 2022
 Current Priorities of the U. S. Surgeon General. Health Worker Burnout. https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html
 Jones Wood SC, Phillips RA. Building Workforce Resilience at the Individual and Organizational Levels. NEJM Catalyst, August 2022. doi: 10.1056/CAT.22.0107. Accessed 20 July 2022 at www.catalyst.nejm.org/
 Helmus TC, Glenn RW. Steeling the Mind. (Santa Monica, CA: The Rand Corporation, 2005.) Accessed online at www.rand.org. Accessed 1 August 2022.
A Good Place To Work
Is your organization a just one? How do you know?
Beyond Toxic Organizations
Are medical organizations toxic environments or is the problem one of changing generational expectations?
Engaging Burned Out Physicians
Unintentional injuries during hospitalization have reverted during the pandemic to levels not seen in years. Authors from CMS and CDC opine about what should be done about it.
Individual and Organizational Stress During the Pandemic
Leading Through Teams
When there is no room at the inn due to staff shortages, the standard of practice will have to change. We need to think about what this might mean.