Leadership and sustained attention from the highest level of the organisation are the keys to any doctor’s well-being according to Prof. Tait Shanafelt, the world’s first Chief Wellness Officer in health, and his Mayo Clinic colleague John Noseworthy. They published their paper in 2017 offering nine organisational strategies to promote physician engagement and reduce burnout. Here I will focus on just one of these strategies: The power of leadership in relation to doctor burnout.
Leadership is a complex set of activities that are not necessarily developed in excellent clinicians. That is to say, different and additional skills are required for a doctor to become an excellent leader.
In the Mayo Clinic study, more than 2,800 physicians rated the leadership behaviours of their immediate supervisor leader.2 For every 1 point increase in the leadership score on the 60 point scale of the supervisor, there was an associated 3.3% decrease in the likelihood of burnout in the doctor and a 9% increase in their level of satisfaction, after adjusting for other factors. After adjustments …”11% of the variation in burnout and 47% of the variation in satisfaction between work units was explained by the aggregate leadership rating of the work unit supervisor, as assessed by their physician reports”.(p135)1
Shanafelt has put this more simply saying, ‘up to half of (physician) fulfillment is explained by the behaviours of [their] immediate leader.”
Effective leadership makes a difference. The Gallup organisation has found that managers have high influence, at least 70%, on their team’s engagement at work. 4 Further they conclude that managers need to have the skills of a coach to be effective so that employees can have the
autonomy they need and seek and so they can receive the feedback they need to develop and grow. To give an example, Gallup’s research found that employees whose manager involved them in goal setting, were 3.6 times more likely to be engaged at work.
It is largely agreed that engagement is the antithesis of burnout. According to Shanafelt and Noseworthy, engagement is “characterised by vigor, dedication and absorption in work” ( p131).1 Contrast that with burnout characterised by exhaustion, cynicism, and reduced effectiveness.
This is where effective leadership can make all the difference. To address this worrying trend of doctor burnout we need multilayered strategies and shared commitment. Leaders are the people who have the capacity to influence this larger system, to change the context.
This seems a great place to start if a healthcare organisation wanted to set a specific goal to reduce doctor burnout. Start by making sure that every person in a leadership role in health is required to undertake foundational training in leadership. And to continue to progress means continuing active leadership development programs. This is not unusual in other sectors.
A workplace mental health strategy and individual skill building programs are important, but they can only be really impactful if leaders proactively and openly engage in them and promote them.
I have met many medical leaders (doctors) who have had no leadership training at all. Of those who have, many of them sought it out in their own time, via community leadership programs. One Medical Director told me last year he felt guilty every time he left work to attend his leadership program because he did not feel his colleagues valued this kind of learning. Well done to him for going anyway! He and his workplace are better for it.
Every doctor I have spoken to who has undertaken a leadership development program has told me how valuable the program has been. These are doctors who have also sought out coaching, so perhaps I have a biased sample. The leadership learning these doctors have done has helped them do their job more effectively, and they say, it has also made them better people. Without exception.
When I have asked them what they mean, they tell me things like, I am more present now, the way I listen to my colleagues and patients has changed, I am enjoying my work again, I feel more connected to the people around me – at work and at home.
It seems to me they have been learning the skills we often refer to as ‘soft skills’, what some recently have renamed ‘power skills. The difference for these doctors is they now appreciate how impactful these skills are and speak of them with reverence, acknowledging how tough it can be to prioritise these power skills, in a world that values technical knowledge and technical skill above most else.
Sometimes they even wonder out loud how they did their job before, when they were only relying on their ‘hard’ (technical) skills and were a bit oblivious to what other skills might be useful in their leadership role.
Of course, doctors have spent a long time investing in the development of their technical skills. The difficulty is, we don’t know what we don’t know and many healthcare organisations have not created systemic leadership education that includes and values the development of these power skills. As a result doctors lead ineffectively and unconsciously help create a workplace environment conducive to burnout.
Leaders who recognise the value of skills like self awareness, self regulation, emotional intelligence, effective communication and compassion, invite their employees to bring their whole capacity to work. Leaders with these skills create environments that facilitate individual wellbeing.
Environments that allow people to express their full experience by taking learning risks, exercising their creativity, using emotions to connect and sharing their vulnerabilities. Such a workspace that truly values soft skills as much as technical skills, can give rise to resilience and engagement in all their glory.
Personal resilience and self-care strategies exist within a context, they are relational. A workplace that recognises the environment’s role in resilience can encourage individual healthcare workers and help them engage at work.
Workplaces that only focus their efforts on individual resilience, can feed burn out. Feelings of isolation, hostility, and cynicism can fester through the lens of “the employer is blaming me and takes no responsibility for what this workplace is doing to me.” While this might seem irrational and simplistic, this is the way a burned out worker can see the world, as hostile and unfair. More than once I have heard sentiments like “they want me to do this resilience training so they don’t have to change the roster”.
As a facilitator of mindfulness and resilience programs I have personally met this cynicism in many healthcare workers. I agree with them: resilience programs offered in a vacuum do imply blame and are limited in the impact they can have. Programs offering to promote wellbeing, resilience, and engagement cannot achieve their worthy goals if they are simply ticking an organisational box.
These goals of resilience, engagement and staff wellbeing, require organisational commitment and effort, including daily routines and lots of repetition over the long term. They also require a range of strategies, no one program will meet all the needs of all the people all the time. In other words workplace design is central to reducing burnout and promoting wellbeing of healthcare workers. To reduce burnout we need cultural change in healthcare and that must be driven systemically by healthcare leaders.
Burnout occurs at a higher rate for doctors than for other workers. “Burned out” is how we describe a person whose wellbeing has been impacted negatively by the demands of their job.
Burnout as defined by the World Health Organisation and the International Classification of Disease-11 (IDC-11) is a workplace phenomenon, not an individual mental or medical illness, bought about by chronic workplace stress that has not been successfully managed.
Surveys show physician burnout sits at around 50% in the U.S. Estimates of doctor burnout are at 50% in Australia too though no-one is publishing any comprehensive data unfortunately. An article published in The Lancet last year called physician burnout a global crisis – before we had a true global crisis in COVID-19 which is likely to have a long tail of healthcare worker mental health challenges. To have this many people burning out across countries and workplaces indicates a systemic and cultural problem bigger than any individual.
This is very concerning for the doctors themselves as there are links between burnout and doctors turning to drug and alcohol misuse, developing depression, experiencing relationship dysfunction and breakdown, and most tragically, suicide.
It is also very concerning for patients. A doctor’s wellbeing has a ripple effect beyond themselves. A burned-out doctor is more likely to provide a lower quality of care, negatively impact the patient ‘s experience, and poses more risk to their patient’s safety. For healthcare organisations there are other financial costs beyond the patient too, with burned-out doctors turning over more and providing less than optimum work effort (presenteeism).
Shanafelt and Noseworthy identified two key barriers to healthcare organisations taking action to promote physician wellbeing:
- The belief that steps to cultivate wellbeing will be in conflict with other organisational goals
- Effective interventions to reduce burnout will be too costly.
Neither of these have been born out in the research to date.
In fact, many studies have found that wellbeing programs pay for themselves with the return on investment (ROI) being greater than 1. Beyondblue for example found the ROI to be $2.30 and Safework NSW found it to be $4.01.
I can’t help wonder what the ROI would be for systemic leadership training over a 10 year period, beyond the dollars and cents. What if we saw a decrease in anxiety, depression, burnout and doctor suicide. It will take leadership vision and systemic commitment to find out.
Shanafelt and Noseworthy point to another very interesting study completed by Horowitz et al. (2003) in terms of leadership. Horowitz et al6 were investigating what makes meaningful work for doctors. They found that doctors who spend 20% of their time in work that they are passionate about, that they REALLY care about, are at significantly lower risk of burnout. You might say that doctors will do the work the organisation requires of them much more effectively in the other 80% if there is flexibility and capacity to do what they most love in the other 20% of time they are at work. Doctors need some autonomy.
To effectively engage doctors in the collective goals of the organisation, leaders need to know what this 20% really meaningful work is for each doctor in their team. This is the kind of engaged leadership investment that can promote individual wellbeing.
This kind of culture is enabling and facilitates resilience . It has the potential to reduce the rate of burnout. The question is how many leaders have the capacity to find out what’s meaningful to the members of their team and then to design workflows that are cognisant of what they learn? And how many doctors can articulate what is really meaningful to them in their work?
I have been privileged to witness this process of learning what is most important to individual doctors, in action, in our Immersion Program and as their coach. Many doctors I work with,do not know the answer to this question of what really matters to them in the work they do. Finding the answer can be truly transformational for them individually, giving them clarity and a future plan that they are excited about and can take action on. When they share it at work and others engage with what they care about, the energy can really change dramatically.
Imagine if you led a team where all the members knew this about themselves and together they were engaged in this kind of conversation. Developing work that achieved the organisational goals and the individual’s own goals. This model is one of engaged and empowered partnerships shaping the future of organisations and individuals in meaningful work. Doctors and their leaders care, they know each other cares and they know the what and why of their work.
Remember that the features of burnout are the opposite of this environment – exhaustion, cynicism and ineffectiveness. In burnout doctors say I don’t care and what’s the point.
There is no guaranteed prevention of burnout, but a workplace that cares about their workers and their goals, is adaptive enough to support them in that work and encourages them to pursue it, is more likely to keep them engaged than not. The leader plays a very significant role in creating the right environment for resilience to flourish.
The leader might also become more engaged and fulfilled….. wouldn’t that be exciting!! And it’s easy to see the positive reinforcing feedback loops in such a workplace.
We understand more about leadership and about burnout in doctors than our current burnout prevalence suggests. We can achieve better doctor wellbeing if we attend to building the leadership capacity of our medical leaders. We need to commit to a two-pronged approach for reducing burnout in doctors: one that is focused on building individual skill and one that accepts burnout as a workplace phenomenon and seeks to address the organisation’s role in creating it. Both need healthcare leaders to set the environmental tone. We can start by prioritising and proactively teaching power skills to all our medical leaders.
To get involved with our doctor development programs for leadership and power skills like emotional intelligence, communication, compassion, mindfulness and self awareness, email me at email@example.com
2. [Shanafelt TD, Gorringe G, Menaker R et al. Impact of Organisational leadership on physician burnout and satisfaction. Mayo Clinical Proceedings 2015; 90 (4) 432-440]↩
3. [Dec 18 2019 Physician Burnout with Dr Tait Shanafelt – youtube with Dr Pavlos Tsantilas Munich Vascular Conference]↩
Shanafelt TD, West CP, Sloan JA et al Career fit and burnout among academic faculty. Arch Internal Medicine 2009; 169 (10); 990-995
Horowitz CR, Suchman AL, Branch, Jr., WT and Frankel, RM. What Do Doctors Find Meaningful about Their Work? Ann Intern Med. 2003; 138: 772–775]↩