Dr. Dike Drummond is a leading expert in employee burnout, who has deep experience with physicians and healthcare systems. In fact, Dr. Drummond has helped over 30,000 physicians with his expertise. He is the Founder and CEO of TheHappyMD.com and is a sought out thought leader on the prevention of physician and employee burnout.
1) Why is physician burnout so prevalent today?
You’ve got the CMO’s (Chief Medical Officer) collapsed distinction that decreasing the stress on doctors must involve more time off or seeing fewer patients. That’s fundamentally not true. We have current protocols in three different places that show that team-based care reduces the stresses of the doctor’s experience of practicing medicine and allows them to just see patients … and they end up actually seeing more patients rather than less.
The study I reference is from Family Practice Management. The program is called the APEX at the University of Colorado run by a doctor, Corey Lyon. What they do is they questioned the evil of the Medical Group Management Association (MGMA) Staffing Survey. That survey is pitched as a monitor of best practices when it is actually one of the key causes of our current burnout epidemic.
Let me tell you a little story. Now that big groups employ lots of doctors, there are organizations of big groups, and the big group organizations do surveys because of big groups like things like “industry standards.” One of these is the annual MGMA Staffing Survey. One of the survey questions is, “How many Medical Assistants (MAs) do you give each outpatient doctor?” An MA is the person who rooms your patient, takes the vitals, stuff like that. And guess what the number always is in the MGMA survey? One. One is the MGMA average. So, when you join a large group, they give you one MA, because one MA is the average in the survey of big groups. What makes you think you’re so special that you should get above the average? Let me just point out what’s the burnout rate these days? 50% at any given point in time. That’s a snapshot, I mean today half your doctors are burned out! Well, I would propose to you that the MGMA staffing average is one of the causes of burnout.
Worse, this data reinforces the conditions that cause burnout. There’s nothing to suggest that the MGMA average is a best practice. It is exactly the same amount of back-office staff that we gave doctors before EMRs (electronic medical records). Yet EMRs increase the doctor’s workload by 30% to 50% as soon as they are implemented. What we’ve done over the years is we have systematically de-provisioned the doctors.
There’s a thing called team-based care. There’s also a thing called a scribe. There’s also a thing called a super MA. A super MA is a medical assistant who can scribe and do other documentation tasks in the chart for the physician.
One of the challenges, if you use professional scribes, especially if you use an outsourced service where you’re hiring scribes, is that there’s a lot of turnover. It can take a couple of months to bring a scribe up to speed with how you’d like to document … so if they leave shortly after, it is painful.
Here’s what the APEX study did. Here’s what they do at Bellin Health — Jim Jerzak MD is the name of the doctor there — they have a protocol where what they do is, they give every doctor two and a half super MAs. In an office wing that has two doctors, you would have five super MAs on staff. This means about 80% of the time that MA stays in the room with the doctor and basically does all the charting.
This is where the APEX study is great; they wrapped the study in what I call CFO metrics. They wrapped it in metrics to appeal specifically to a Chief Financial Officer. Within six months, the burnout rate went from 50% to 15%. And, that is not all.
The clinics went from understaffed, short MAs and doctors, to waiting lists for MAs and doctors to join the staff to work in that environment. The quality indicators, the things that they were being measured on, vaccination rates and mammogram rates went through the roof. Patient wait times disappeared, patient backlogs disappeared, patient volume increased to make it revenue neutral. These physicians were seeing more patients, less burned out, hitting their quality indicators. Turnover is zero, and they’re rolling it out to every primary care clinic in the University of Colorado system as fast as they can train people up.
So, for a CEO or a CMO to think that the only way they could possibly relieve the stress on the doctor is to give them more time off or let them see fewer patients is a ringing indictment of the cruelty of our current systems of care. What they’re doing is dominating the pieces of slack the doctors have in their workday, even while sitting at home at night, because EMRs mean that they must keep up with the documentation when they get home. When we talk about exploiting the professionalism of the physicians, EMRs are a prime example of it. You doubled my workload and you fail to upstaff me, and then you asked me what’s my problem when I can’t keep up. And you think the doctors are the problem? That’s craziness.
So, I think that the organizations that are going to be successful in the future are going to be ones where we do team-based care. We upstaff, we support the doctors to go fast. This isn’t a problem with the doctors. A big component of this is simply a staffing issue.
2) One of my favorite pieces of advice from your work is that we all need to party a bit more. When you prescribe this helpful tip to physicians, what is the science behind it?
I don’t know that there’s science behind it but let me ask you this: if your four-person physician group was bought by a 300-doctor group that’s located around your local hospital … your people used to own your practice, the four of you … you’ve been friends for a while. You’ve run this practice, you know everybody’s significant other, you know each other’s kids, right? And now you’ve joined the 300-doctor group, and then at that 300-doctor group, you haven’t changed your office, your office is still where it is, but you sold it. Right? You can’t even hire and fire and manage your own staff anymore. Your new employer is in charge. And this huge group has one annual holiday party. They do an annual medical staff meeting once a year or at holiday time, and what happens is all the individual groups that have joined into the collective sit at their own tables with each other and they don’t interact.
The people who are now my partners in this larger organization used to be my competitors, and we only have one opportunity to have fun together and get to know each other once a year. What does that do to your morale? Are you going to feel like somebody’s got your back? Are you going to feel like you’re a member of your new group? Has this increased the purpose and meaning in your practice, this merger that you did?
No. It’s a lonely, gerbil-wheel-spinning existence. It’s horrible. You can’t build a culture if you don’t know each other as people. You can’t know each other as people because in the practice of medicine, the doctors are in their own offices, on their own gerbil wheels.
We never see each other. We must have opportunities to meet, connect, and get to know each other outside of our work hours. If you want any culture at all, you need to have an active social calendar. It doesn’t have to be all 300 of those doctors getting together. But it could be interest groups, right? It could be the triathletes, it could be the bowling club, it could be the writers, it could be the Tai Chi group. You must have things outside of medicine that are sponsored specifically for the physicians because physicians tend not to attend things that are for all staff. This should be a signature piece of the organization’s strategy to prevent burnout. It’s one of the four buckets of the strategy I teach. It needs to be a big chunk of what your burnout prevention group, or your physician wellness committee, or whatever you call it, manages — an active social calendar for the physicians.
You can’t have a tribe if you don’t get together. Even worse, your big medical group will often make that annual medical staff holiday meeting mandatory. BIG MISTAKE. Totally anti-culture in your group. It’s totally anti-belonging. It’s totally anti- “somebody’s got my back”. Bad leadership is everywhere, but bad leadership and the disconnect in the cultures of organizations have different consequences depending on what the industry is. In medicine, patients and doctors die every day because of burnout, spawned at least in part by bad leadership and systematic overload at the front line. People die.
3) Another strategy you suggest is to mitigate burnout by playing games. What is it about fun and games that make these things helpful in reducing burnout?
It all depends on how they are deployed. If you say, “Hey everybody, your work conditions suck, let’s play a game,” that is not going to work, but the fundamental behind this is that being a doctor is no fun.
All we’re ever looking for is disease. Our training is an act of nurturing our paranoia. I don’t know if you understand what the process is that we call differential diagnosis. Differential diagnosis is an exercise medical students and doctors always go through where I give you one symptom and you tell me all the different diseases it can represent. We’re always thinking about disaster scenarios. We’re always overloaded and behind, there is minimal opportunity for fun in the average day of a doctor.
If you can introduce something that makes something fun, it’s a shocking difference and it starts to bring in gratitude and connection in ways that wouldn’t otherwise be there. Let’s be clear though, if you try to do that without addressing the fundamental issues of the inefficiency of the systems of care in the organization, you’ve just completely shot yourself in the foot … don’t attempt to make me play games when the overarching system sucks.
4) You have some great insight into the importance of bucket lists. For my own work, I’ve adapted this practice a bit into maintaining a fun file. What are some the best ways you’ve seen people ensure they reconnect to things outside of work that bring them joy and actually follow through on experiencing life?
One of the things that happens when you’re a doctor, and it happens as soon as you go into medical school, is that the burden of the studying that you have to do and the number of hours you have to put into the work means that when you enter into the medical education system, you will radically prune your relationships and your hobbies. What ends up happening is you get a person who’s a workaholic, superhero, lone ranger, perfectionist. The classic components of the conditioning of a doctor get created very, very quickly because there’s just not enough room in your life for all the things you used to do and have fun with.
One of the things I teach medical students, residents, and doctors is to have a hobby or two and have a series of relationships that you maintain, but your ability to maintain them is not some talent, some skill, something that some people have and some people don’t. It’s a structure, and so I teach a weekly scheduling method where you grab a paper calendar once a week and create what I call a life calendar.
Every doctor has a work calendar, typically in their phone. It shows the shifts they’re working and when they need to be on call. The calendar I am talking about is about life. It’s what you want in your life. You use colored pens to put down anything you want in your week. Maybe it’s a glass of wine with a friend, maybe it’s a birdwatching club, maybe it’s a massage, yoga, whatever it is. Every doctor has what I call a weekly bucket list. Every doctor has a couple of things they do for themselves just once or twice a year. Almost all doctors need to do activities that aren’t work-related more often.
You use this schedule method to hack it into your available time more effectively. It’s just the one week ahead mapped out on a paper calendar. You simply take a picture of it with your cell phone. That way you’ve got your life calendar on your phone and you can compare it next to your work calendar when needed. That allows you to start practicing the magic two-letter word of life balance, which is the word “no.” The reason you now say no is because you’ve got the evidence right there on your phone in that calendar. You’ve got evidence that you have a life.
If you take this on as a habit with your call rotation, or with the people that you work with and everybody’s building life calendars and sharing what they’re doing, it gives each other space to have a life. It can totally change the culture of your office, or your practice, or your wing or your ward. It’s a structure, it works every time I get someone to use it.
There’s friction because there’s a whole bunch of programming to overcome. Doctors have a prime directive: never show weakness. When you say no, people will torque that into the “never show weakness paradigm” … into “you’re not a team player, you don’t pull your weight.” For the long-term health of us as a care team, we need to have lives outside of work. This provides you with an artifact to make a life outside work more accessible.
Everybody has habits that are laid down in residency education, residency is meant to be survived, but that lifestyle is not meant to last forever. So, you have to unlearn your residency habits when you’re out in practice because you’re now in this for the long haul. Sometimes it is difficult to recognize that you are programmed and do have automatic behaviors that aren’t useful anymore. It is even more difficult to reprogram yourself when these deeply conditioned habits are shared by your whole group, which is often the case.
5) What advice do you have about the practice of reflection as a tool against burnout?
For a physician, anytime you walk into your practice, you’re walking into the middle of a whirlwind, a hurricane, a tornado of stuff coming at you from all directions. From the inside of the whirlwind, you only have one viewpoint. You only see the inside walls of the whirlwind and the only thing you see are the things that aren’t working.
If you never get out of the whirlwind to look at the whirlwind from a new perspective, you’ll never be able to see patterns or make changes. I find that the healthiest people, not just doctors, the healthiest people in general, step out of their whirlwinds at regular intervals to look at the whirlwind and say, “Hey, how’s it going? And is there anything I want to change here?”
It’s the structural equivalent to, “A life unexamined is not worth living,” or Einstein’s quote, “No problem can be solved from the same level of consciousness that created it.” Examples of stepping out of your whirlwind to reflect upon that experience from a new perspective are the team huddle. You get together outside the whirlwind as a team before you dive into the whirlwind consciously and start seeing patients that day. The team huddle is a great example of reflection. Another is the monthly staff meeting. The whole group gets together once a month to look at their individual and collective whirlwinds and see if they want to do something different.
