Podcast: Fighting burnout in health care

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri … the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, in this episode we look at an effort to battle burnout among health-care workers. After two years of wearing protective clothing and working on hospital floors crowded with COVID-19 patients, many doctors, nurses, therapists and other front-line workers are suffering with anxiety, depression and other difficulties. And now, armed with a grant from the Health Resources and Services Administration of the Department of Health and Human Services, Washington University mental health researchers have begun studying ways to get health workers the help they need to keep going through this relentless pandemic. Washington University psychiatrist Dr. Ginger Nicol is the study’s principal investigator.

Ginger E. Nicol, MD: I often will tell people, “If you’re feeling anxious and you can’t sleep and everything just feels like it’s out of control, of course you’re going to get depressed. Of course you’re going to feel anxious. Of course you’re going to not want to get out of bed the next day. And if you had any other reaction than that, I would be suspicious of you.” This is a completely normal reaction to a terrible situation.

Dryden: Problems with burnout aren’t limited to the doctors and nurses in COVID wards, and the School of Medicine has been working to address issues regarding the mental health of medical students and other trainees. Dr. Eva Aagaard is the senior associate dean and vice chancellor for medical education.

Eva Aagaard, MD: In general, we’re trying to reduce barriers to help seeking and normalize struggle as part of the journey.

Dryden: Aagaard says part of a curriculum update at the School of Medicine has involved stressing to trainees the importance of wellness and self-care. Meanwhile, with the new grant, psychiatrist Ginger Nicol will work with occupational health specialist Dr. Brad Evanoff and fellow psychiatrist and wellness specialist Dr. Jessi Gold to develop mobile technologies that are designed to help front-line health-care workers find help and get help when they need it. Gold says the biggest part of that battle involves getting those who need help to actually seek it.

Jessica A. Gold, MD: There are lots of organic barriers for health-care workers that make it particularly challenging for them to ask for help, even if the help is available. One is simply knowing that resources exist, but there are so many other things in the way that even just knowing what exists, they can’t actually go get it, right? So if you look at a trainee’s schedule, try to tell them to go to therapy once a week — when can they do that? It’s impossible, really. They work all day. They don’t have control over their schedules. And in health care, there’s a lot of stigma towards getting help, what it means to ask for help. And so if you’re going to be doing something that’s once a week and you have to ask permission for that, then people assume things. And what that means in health care is, are you weak because you need help? Are you somehow not a good doctor because you need help? And all of those things are backed by research. It’s not just an invention of what we hear. It’s actually what people believe. They think it’ll prevent them from getting to residency. They think it’ll prevent them then from being appreciated by their supervisors or viewed the same way. They think it’ll affect how people view them as a doctor, right? So all of those things can get in the way. And then, simply, I can tell you signs and symptoms. I can tell you sleep is important. I can tell you if you’re sad, that’s something to be looking at, right? But if you look to the person next to you and they get as much sleep as you do, and you look to the person the other side and they eat as much as you do, which is never, you’re going to say like, “I’m pretty sure this is just medicine. I don’t actually think there’s anything wrong with me.” So our baseline is also way off because you can’t calibrate your needs versus anybody else. And maybe what would look like depression or burnout in a different population is really hard to know in medicine. So it’s not just, what does that mean for me, and what do people think about me? It’s, isn’t this just medicine?

Dryden: But is it just medicine? Because it’s not uncommon for people in all kinds of professions to want to avoid the employee assistance program. I mean, not asking for help when you need it is not unique to medicine, right?

Nicol: A layer added to all of the challenges that Jessi mentioned is COVID.

Dryden: This is Dr. Ginger Nicol.

Nicol: This is like the longest disaster we’ve ever had. A really good example of work burnout and exhaustion is Zoom fatigue. And part of the reason that that is a fatiguing thing is that you have to really put so much more effort into listening and looking than you would if you were in the room with another person. So you have a day full of Zoom meetings, you’re going to be a lot more tired on top of what already was a pretty unfriendly work culture in many places before the pandemic. Employees everywhere are experiencing this. Health-care workers have to be available all the time. We are expected to take care of people. And so now there’s even greater need than before, and we’re sort of working through, what does this mean? What does it mean for mental health? I think the pandemic is really going to change how we look at burnout and exhaustion and how does that turn into depression, anxiety? These are real things. And when we see health-care workers clinically, we’re sort of reminding them that we see them outside of Zoom, right? We see that they’re suffering and that the suffering and the frustration and the angst, that’s all a natural reaction to something that’s really happening. And so validating that, normalizing it, saying, “I feel that way sometimes, too.” I often will tell people, “If you’re feeling anxious and you can’t sleep and everything just feels like it’s out of control, of course you’re going to get depressed. Of course you’re going to feel anxious. Of course you’re going to not want to get out of bed the next day. And if you had any other reaction than that, I would be suspicious of you.” This is a completely normal reaction to a terrible situation.

Gold: Everybody is struggling during COVID, which is what Ginger is talking about, right? But if we don’t get help, why should anyone else get help? If we can’t talk about mental health, why should anybody else? If we think that there’s a stigma to it, we’re going to pass it down. We’re going to judge the people who have mental health conditions, and it just perpetuates a significant domino effect. We have to be role models in this, and it’s not something we’re comfortable doing, but it’s something we have to do.

Dryden: Is it just the relentless number of folks that health-care workers are dealing with? Is it the fact that it just keeps going? Is it some combination? What is it that makes this harder than car accidents or cancer patients or other emotionally wrought things that a health-care worker has to deal with?

Nicol: I think the biggest thing is that we’ve never had anything last this long. And so the volume and the need — when you have burnout and you have that situation, it’s multiple waves of burnout, right? And when the problem is the same, you start to think, “OK, there’s no way out of this.” And when it feels like there’s no way out, that’s when burnout becomes depression.

Gold: I’ve had this conversation with a lot of health-care workers, which is, “But in your job, you see X. Why is this so much harder? You’re an ICU doc. You’re used to death. You’re an ER physician. You’re used to being busy and having a lot going on. Why is this so much harder?” And every single person says some version of the same thing, which is, “Yes, I was used to that. This is not that.” Which is ICU physicians are seeing people they aren’t used to seeing die, die. ER doctors, same kind of thing: Being exposed to something that can make you sick when you are an ER doctor is not something you’re really used to all the time. This was something that could not just affect you but your family, too, which makes your job different. Palliative care doctors, whose job is literally to usher people through death, have told me, “This isn’t a good death. If I had a choice and we were planning this and helping people, we’d know ahead of time it was going. We’d be able to really help them through their pain. Their families would be here.” And a lot of times, their families haven’t been because of COVID restrictions. And so these changes that might not be something that people in health care are like aware of, because you could say, “Well, duh, you chose that hard job where you see death all the time.” You get used to it, but when it changes and you don’t have control and you can’t help people, or you’re in palliative care and you actually are OK with death but you want it to be done in a way that’s respectful and in the way that the family and the patient want it and you can’t and it’s so out of your hands and all you want to do is help people … it’s just not a good thing.

Dryden: So you know that this is the way things are. This is the way things have been. You’ve got this new grant now that is designed to help these people working in health care to get help if they need it, correct?

Nicol: It’s a services grant. And that’s kind of a unique thing. The Biden administration puts money aside specifically for this issue because we know that if we don’t take care of health-care workers, nobody’s going to get better. And the funding is really to help institutions help health-care workers just access what’s there. So it’s really, what can we do to help people be able to stay resilient? And so this is where we have been having a lot of conversations about, how do we help people recognize that they need help? How do, then, we help people feel comfortable saying that they need help? And then how do we help people find the right kind of help? This grant is really to help not create new services but help health-care providers find what they need and to understand what it is that they’re going through. So, right, we’re normalizing or we’re minimizing or we’re compartmentalizing — these are ways that we get through the day. But ultimately, that isn’t really the right way to help address the problem. So we have to help people to talk about it.

Dryden: So as I understand it, you’ll be using web-based mobile technology, try to offer people help, help them maintain their well-being. So how does that work? Would that be, like, a nice thought for the day is going to appear on my iPhone, or will there be regular surveys to fill out? How will people interact with this interface?

Nicol: The platform that we’re going to be using, we built in partnership with the Healthy Work Center and Dr. Evanoff. And it originally started as a health and wellness text messaging intervention that was loosely based on the diabetes prevention program to help health-care workers with healthy weight loss or maintaining a healthy weight and just lifestyle things. And so one of the things that we’re going to do is try to repurpose that platform to help people learn about themselves, to become self-aware, to set goals, and then to help them, as we give them an assessment, use that assessment to help them find the right tool. So one of the things that we think could be helpful about this is as we link into these services that already exist, we can triage better. We can more efficiently use what we have and get people feeling better.

Gold: When people hear app or they hear text messaging, they’re like, “Oh good, another thing that’s going to burden me. I have to take out my phone, I have to get more emails. This is the worst thing I’ve ever heard. Why do you want to do that?” Right? Because we get a lot of incoming notifications that cause anxiety as is in our jobs. We want to make something that helps you and that you actually use and want to use, and so that requires talking to a lot of different people and really understanding how to do that, including how you shape the messages. Because if you’re really stressed out and you get a positive word of the day, that’s not helpful. Therapy can be beneficial for everyone, but it doesn’t mean you actually have to see a therapist. Some of those skills can be built yourself, like, “What are my strengths? Why? How do I learn boundaries?” These things that we can teach that make you better at your job that no one taught you in school.

Dryden: Cases have been declining. Omicron seems to be going in the right direction. So by the time you figure things out, will we still be dealing with new strains of COVID, or does it even matter? Because you have to figure these things out just because health-care workers need to know what they need to do.

Gold: As a mental health provider, I do not go, “When COVID’s over, people are fine.” And that’s because all of these health-care workers haven’t even like stopped running. They’ve just been running for two years straight. And so when they stop and actually breathe, they’ll go, “Oh, turns out I haven’t slept. Something’s wrong with me. I need help.” Trauma itself doesn’t really have a timeline, so you could be a year from now in that same room that you had a COVID patient die, and all of a sudden, you feel your heart racing, and you have trouble focusing, and you can’t stay at work. That’s from COVID, but it’s a year later, right? So when you think about that, why is it going to get any better? Frankly, it’s just going to compound everything that was there before and keep going. So we have to build. We’re going to need to keep this as something that the hospital and the medical school and the world, frankly, cares about for a long time because this can affect us for a long time.

Dryden: And Eva Aagaard, the vice chancellor for medical education, says changes in the way the school is training students may help alleviate some of these problems in the future.

Aagaard: We are very lucky here to have truly outstanding medical and mental health access for our student population, whether it’s medical students, OT, PT or graduate school, through our student health services. We do regular activities to reinforce well-being all through their curriculum, including things like mindfulness training, support groups, reach outs during times of stress and strain, pet therapy, encouraging physical well-being, supporting financial well-being, and encouraging conversations about those issues, and then actively trying to encourage the use of mental health resources that we provide.

Dryden: Not necessarily seeking help is not unique to professionals in health care. A lot of companies have EAP programs, and people don’t use them. What can you do not in just having the services there but in training the mindset of the people to say it’s OK to ask for help if you need it? And, I mean, these are extraordinary times, obviously, but pressure and burnout are not uncommon in medicine in normal times either.

Aagaard: It’s both about making that access easy, but it’s also a lot about changing culture. And there are a couple of ways that we’re trying to do this in the MD curriculum in particular. In general, we’re trying to reduce barriers to help seeking and normalize struggle as part of the journey. And so we’ve done that through changing the way we assess our learners and changing the learning environment, creating a coaching program, having low thresholds for reaching out to learners when we see any kind of evidence that maybe they’re struggling in some way, whether that be a lack of attendance or a less-than-stellar performance that maybe is out of character for them or just noticing that they don’t seem quite themselves, making it as easy as possible to access services and to destigmatize access to those services. In the curriculum, we did a couple of things. One of the big things we did is we changed completely the way we evaluate our learners, the way we assess them. And we have a longitudinal competency model with a lot of formative feedback to help students get up to speed. And that reduces stress but also normalizes the process of being good at some things and less good at other things and that that’s OK, it’s normal and that you can keep working through it. The second piece was coaching, which has turned out to be an incredible resource for our students. So each coach has eight to nine students per year that they are working directly with. They meet with them on a regular basis, usually about twice per month in the first phase of the curriculum. And this is really about creating a cohort of people who trust each other and who can have conversations about stuff like this. But it’s also about having a faculty member who really knows the students and who is nonevaluative. They don’t evaluate that learner, so there’s less pressure to perform in front of them. And so this has been a big part of it. But also in the curriculum, we talk a lot about self-care.

Dryden: I want to know, professionally, if there are ramifications for a health-care professional who seeks help for burnout or for depression or anxiety, specifically regarding things like licensure, that sort of thing.

Aagaard: I think the way that I interpret these issues is that early help seeking, before something bad happens and the condition that you’re facing impacts your ability to safely do your job, actually protects you. And late access can cause you very serious harm. And so moving to these early intervention, early outreach, early access, maintaining stable mental health as much as possible is really critical to protect people’s licensure in the long term. And I think there’s still a lot of work that needs to happen at the state level and within licensure to normalize challenges with mental health and to help get this issue out of the way so that people are getting the help they need and not hiding for fear of losing their license or not being able to practice anymore.

Dryden: While Aagaard and her colleagues in medical education are working to teach future health-care providers not to be afraid to ask for help when they need it, Nicol and Gold are working to match people who already work in clinics and on wards with the help they may need. With any luck, COVID-19 will be just another seasonal virus one of these days. But problems for health professionals with stress, burnout, depression and other issues won’t be fading into the background anytime soon.

“Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.