Coaching is Vital to Preventing Burnout in Physicians

From the 5/14/2021 newsletter

Perspective/Opinion

Coaching is Vital to Preventing Burnout in Physicians

Brett Linzer, MD

Dr. Linzer shares how some of his peers suffered, then explains how coaching and intentional support can build resilience, improve the work environment, and restore meaning in our work …

My internal medicine/pediatrics friend Alex Djuricich, MD killed himself a few years ago. He was one of my resident partners and eventually became the internal medicine/pediatrics program director at the Indiana University School of Medicine.  He was a mentor to many internal medicine/pediatrics physicians and a father of two teenage daughters. When he died, I promised myself that I would do what I could to help other physicians.  It has taken me a long time but, with some of the work I am doing, I feel as though I am making good on that promise. 

I spent years trying to figure out why doctors hurt themselves. I am not sure if I have figured out much, but I have learned a lot along the way.  

One of the most important things I have learned is that I do not have all the answers to my life. But, I found a lot of the answers through coaching.

Why is coaching important?

The idea that we, as physicians, can figure everything out on our own and not rely on others to help us is, at best, a poor strategy for success and, at worst, a dangerous myth. Physicians are highly trained and skilled in certain areas but may lack mastery in relationships and communication. After residency, there is little emphasis on personal growth and especially emotional development.

Coaching can bring wide-ranging benefits to any organization. Most experts agree the cost of replacing one physician, including lost revenue, can be around $1M. A well-coached physician is more likely to stay in their current position and, therefore, save the cost of recruiting a replacement. In addition, there is less physician burnout, improved mental health, more effective physician leadership, and more balanced and engaged physicians. When physicians are at their best, everyone wins.

The struggles hit close to home

During my training, I was no stranger to suicide. A medical school classmate killed himself. 

Then, an international graduate with two children and a family in China hanged himself during the second week of our internship. We all knew he was struggling but had not known what to do. We were treading water ourselves.  The next morning, the residency program director brought our group of ten interns into a room and talked to us. "This is bad,” he said. “We care about you.  Here is the card for the psychologist. Call if you need help." I looked around the room at the other confused faces and honestly thought, what does he mean by “need help”?  I said to myself, Look Brett, screw your head on straight. You are on call and have a busy service. You need to get back to work.  

Two years later, my chief resident shot himself. I thought he had all the answers. He was a smart guy and had a desirable GI fellowship lined up. At the funeral, I went up to people I knew. Do you understand this? Can you explain this to me? Can you please tell me he had some label or diagnosis or something that I do not have? Chronic depression, alcohol abuse, or schizophrenia? Something? Anything?  How do I know I am not next in line?  There is always a line. On average, one physician commits suicide every day in America.  Every day!

But I was not next in line. Next in line was my friend Alex. He was considered by many to be the ideal internal medicine/pediatrics academic physician. I went to his wedding.  He met his wife when she was a fellow intern with me and Alex was our resident.  He had a family.  He even looked like me. How are they different than me? How close was I to where they were?

Look Brett, I said to myself. Screw your head on right.  You have a lot of … wait … it is not working.  You cannot figure it out. Who's next in line?

Then, one of my best friends and close partners left our organization. I had difficulty understanding why he left and felt the effects even more acutely when I had to absorb a number of his patients. This was the height of the opiate epidemic and some of the patients were very difficult. I did not know how to manage them well. In addition, I had an unmotivated, depressed medical assistant working with me and I did not know how to communicate with her. The triage nurse in our small clinic was not motivated to do her job. I was not comfortable with conflict, so I avoided her and did extra triage work. The clinic manager was too scared to confront the problems. The administration was well-meaning but not helpful. 

I felt like I was playing a new game and I did not know how to play it well.  I did not even know how to tell if I was successful.  Press Ganey surveys did not do it for me. About this time, Epic came online, and I struggled with efficiency. My wife had chronic debilitating migraines and we had three teenagers at home with no family support. I had extended family challenges. I was cut off from my emotions and I unknowingly built walls to contain them, not knowing I was cutting off my good emotions as well. 

A turning point and finding help

In 2014, my survival skills were not serving me. Life was closing in. I was tired, frustrated, angry, irritable, confused, fearful, and more. I took care of depressed patients and I prescribed SSRIs for them.  Would an SSRI help me?  I did not even have a doctor. Maybe counseling would help, but I did not know where to turn.  I did not have the time. 

I was too scared. During one particularly rough patch, I asked myself if I was suicidal. 

One night, I was sitting at home and finishing Epic charts. My wife handed me a card that said, "I think you need some help." I looked at the card that suggested I contact Dike Drummond, MD from the burnout prevention program,  www.TheHappyMD.com 

I said to her, “Don’t worry.  I just need more time. I can figure this out on my own. I just need to work harder.” 

My wife had heard me say this before. She was losing patience and my words were not as convincing to me as they had been before.

I asked myself, “Am I depressed?” 

I called Dike and set up a discovery session. This is a free one-hour “get to know you” session with the burnout counselor. At that point, I still did not trust him or anyone else. More than once, I almost cancelled the call. I thought, he does not know me. I am a very private, introverted person with my special problems.  

The next week, I completed the call and was shocked to discover within twenty minutes that he could see right through my walls and defenses. He saw the scared kid behind the walls. He saw and knew my patterns of behavior and thought. He knew where that place was, because he had been there. I broke down and agreed to work with him.

Dike explained that many of my patterns of behavior and emotion were not unique to me. There are patterns that are unique to physicians and emerge from our training.  Many of these are survival adaptations. This stunned me and was so reassuring. He told me I was not broken. There were patterns I could learn about and then modify.

Here are some of the typical patterns and misconceptions that Dr. Drummond described that physicians adopt that lead to burnout:

• If I just work harder, things will work out.  
• I am a smart guy/girl, so I will figure it out.
• I need to do it all by myself.
• I do not want to deal with this difficult patient, nurse, etc.
• Compassion is important for other people but not for me.
• My emotions are not safe.  I need to protect myself.
• I feel like an impostor.

My work with Dike centered around twice-a-month one-hour coaching calls where we worked on emotional and skill development. We started every call with five minutes of gratitude and appreciation. What would I like to congratulate myself for?  What did I do right?  This was actually hard for me because I was more in the habit of beating myself up for what I had done wrong. I could easily list all the negatives, but I had trouble seeing the positives. After that, we would complete the work for the day. Some of the emotional work involved processing difficult emotions like shame, fear, anger.  I realized I had a lot of shame. For example, we discussed:

• How to gain better access to my emotions and feelings.  
• How to trust myself and others.  
• How to have more self-compassion and more compassion for others.  
• How to absorb positive feedback and not deflect it away.  
• How to have a soft front and a strong back.

The area of skill development was wide-ranging. Communication skills were huge. I realized if I could be a better communicator, I could save a lot of time and prevent a lot of negative emotions. As I became better, I noticed how ninety-minute disagreements could turn into fifteen minutes. Three meetings could be one if I was more effective. Three-day arguments could be resolved in thirty minutes with deep listening and full presence.  

We did in-depth personality testing and self-awareness, and I learned how to more effectively interact with different personality types. I learned how to deal with difficult people like the nurses and patients. We did role-play and scripting.  

I realized that as I took more responsibility for the interactions, I developed new skills and the nurses changed their behaviors. In the past, I had believed that my role was to give the right answers, but I learned it was more important to develop the art of asking the right questions. I discovered how to run an effective meeting. What is the goal?  How do we know if we achieved the goal?  Can we stop after thirty minutes and consider it a success if we reached our goal?  I mastered Epic documentation techniques, created succinct, appropriate notes, learned stress management breathing techniques, mastered time management/batching approaches, practiced delegation, adopted marriage skills, enhanced my communications, and made firm dates on the calendar. I had been transformed.

Emerging from the other side

Coaching has changed me.  When physicians are at their best everyone wins.  As physicians, we need to trust, ask for help, and be supported along the way.  We need good leadership that makes coaching easily accessible, affordable, and encouraged.  We could spend one-tenth the amount it takes to replace one physician and invest it in the few hundred we already have. 

It is critical to understand that coaching programs are not just for impaired or problem physicians. These approaches are for growth minded, striving physicians who want to improve their lives and the lives around them. Highly achieving people in many fields have coaches.  Every sports superstar has a coach.  Most high-level business leaders have coaches.  Every coach I know has a coach of their own.  And the people at the top   the ones who train the other coaches - have networks of support and growth systems around the country.

It starts with each of us

Here is what you can do.  It all starts with you.  Take care of yourself and trust that others may be able to help you. Realize that you may not have all the answers to your life.  Reach out to others for connection and for mutual support.  Consider coaching for yourselves.   

Brett Linzer, MD is board certified in both internal medicine and pediatrics. He has been in practice with ProHealth Care for over twenty years. He has been a part of the Medical College for 18 years as a preceptor and mentor to 4th year students in his ambulatory clinic in Oconomowoc. He is the recipient of the Marvin Wagner preceptor award, ACP Wisconsin Community Physician and mentor award and the Milwaukee Academy of Medicine award for excellence in teaching. He can be reached at balinzer@phci.org 

To Kill A Year - Poetry by Olivia Davies

 From the 5/6/2021 newsletter

Poetry by Olivia Davies

To Kill A Year

I wish I could show you in news clips

The loud clang of the beginning,

The silent empty of the middle,

The painful drone of the end

I wish I could show you in pictures the loss, 

But it was hidden behind, between, below

masks

the most deafening silence

the most provocative noise

I wish I’d never have to show you at all.

Olivia Davies is a graduating 4th year medical student who will be starting her residency training at Massachusetts General Hospital this summer. Her poem, To Kill A Year, will be featured in the upcoming edition of MCW’s Auscult: A Literary and Arts Journal.

Ms. Davies is an Associate Editor of The Transformational Times. 

COVID-19 Vaccination Clinic Reflections from MCW’s Research and Clinical Nurses

From the 5/6/2021 newsletter

Perspective/Opinion

COVID-19 Vaccination Clinic Reflections from MCW’s Research and Clinical Nurses 

Compiled by Hope Campbell, MSN RN 

Ms. Campbell, a research nurse in the Department of Neurology, volunteered in the MCW COVID-19 Vaccination Clinic. In honor of National Nurses Week, she offers her reflections on that experience and has compiled messages and thoughts from several other nurse-volunteers … 

Happy Nurses Week to all the MCW nurses and nurse practitioners! 

When I started working remotely in March 2020, I felt helpless and guilty that I was in the position of being able to work from home while my nurse friends were working on the front lines in emergency departments and ICUs.  I felt like I should be out there alongside other nurses caring for the very sick. My position as a research nurse made me feel like an imposter.  

When the opportunity arose to administer vaccines at the newly created MCW COVID-19 vaccine clinic, I knew that I wanted to be part of the effort.  After the MCW pharmacy students, who were “first-in” vaccinators, had to return to their classes, our group of MCW nurses and nurse practitioners volunteered on a regular basis to work alongside the pharmacists, pharmacy students, medical students, physicians, and medical assistants to staff the clinic.   

I’ve worked on this campus for almost twenty years but have only been employed at MCW for three. Meeting people and being able to volunteer was incredible.  All of us had other duties within our departments, but still made the time to volunteer because it felt great to be a part of something so meaningful.  

During the vaccination clinic, I met coworkers face-to-face that I had previously met only via email.  I had emotional conversations with community members coming in for vaccines that had not spoken to another person out of their “bubble” in eight months. After a year of being apart, families would now be planning get-togethers, thanks to the MCW vaccine clinic.  I even had the opportunity to vaccinate my parents and my sister.  I listened to stories of family members that had died of COVID-19 and how thankful the person sitting in front of me was that they could get the vaccine. I’m thankful for these short but powerful conversations that were had. They will stick with me for a long time.  

The beautiful thing about being a nurse is we can serve and provide care in so many ways.  That doesn’t make us any less of a nurse if we aren’t a front-line worker. I’m so proud to have been involved in the clinic even if it was a small role.    

Here are the thoughts from some of the MCW nurses that volunteered in the clinic:

Barbara Shimada-Krouwer, RN, BSN

I’ve been an RN for over thirty-six years. I felt that being a nurse was my “calling” since I was five years old. I’ve specialized in neuro, cardiovascular, and clinical research. 

During my career, I’ve cared for hundreds of patients, from post-op spinal fusion and stroke patients to CABG and post-cardiac catheterization patients.  I have been part of countless research studies that were designed to provide new advances in pharmaceuticals, treatments, and devices to treat a myriad of diseases. I have even treated COVID-19 positive patients involved in clinical trials.

The thanks and tears of gratitude that I have received from those that I have vaccinated will forever be part of me. People were grateful for many things: 

Vaccinated to see their first grandchild. Vaccinated to be able to hold their elderly parent in a nursing home. Vaccinated to be able to go back to work. Vaccinated to save their life. 

Because of the sheer gravity of this pandemic, I feel that I have been able to contribute at least a small part in getting this infection under control. The vaccination team coordinators were truly amazing. It was inspiring to work alongside so many dedicated professionals that shared the same goal of getting people vaccinated!

Being able to be part of the COVID-19 vaccine clinic has been the most important nursing role that I have ever performed. The countless lives saved, and illness prevented is why I am a nurse. 

Karen Schmidt, RN, CCRC

As a nurse who has been out of acute care and unable to help in the direct care of COVID-19 patients, this was a great opportunity for me to utilize my nursing skills to help be part of the solution to this pandemic.

It was a joy to help out in the vaccine clinic!  I loved meeting all the very appreciative vaccine recipients and volunteers from all over campus.  I really appreciated how well the clinic was run, and the focus on teaching whether it was educating recipients on the vaccine or watching the pharmacy and medical students learn how to give their first IM injections.

Roxanne Pritchard, RN, BSN

I was honored and excited to be able to volunteer in the vaccine clinic and appreciated the support I received from my department which allowed me to volunteer in the clinic during normal work hours.

I looked forward to meeting those who were being vaccinated – to hear their stories, discuss their concerns, address their questions and ensure their safety and well-being.  These experiences reminded me why I became a nurse.

I was in awe of the number of faculty and staff who volunteered their time in the clinic and was proud to be a part of a very organized process involving multiple departments within MCW. 

Sonya Carpenter, RN

While my role was primarily administering the vaccine, I was impressed to see what it took to run a clinic comprised of volunteers to take on this huge task. Everyone involved, from front door screeners to the staff preparing the vaccine and monitoring the vaccine expiration time (six hours from drawing up to in a person’s arm) to those cleaning the workstations after every participant to the vaccinators, to the volunteers monitoring the patients for 15-30 mins afterwards for risk of anaphylaxis were wonderful. I was very honored to be part of a team that included volunteers of all areas MDs, pharmacists, nurses, medical assistants and administrative staff. This vaccination clinic has vaccinated over 10, 000 people.

To prepare, I read up on patient education for the participants (what to expect after receiving vaccine). Still, I was surprised by the number of questions people asked. Many people had gotten their information on social media and from news outlets. Unfortunately, a lot of what they had learned was not from reputable sources, so my advice was often to check with their healthcare providers, the CDC, the Wisconsin Department of Health Services, and other reputable sources. 

I consider myself very fortunate that, as a front line worker, I was in one of the first groups to receive the vaccine. The people to whom I administered the vaccines were primarily over sixty-five, educators, childcare workers, police, fire, and correctional staff. Many of them were so grateful and humbled to be able to receive this vaccine. It was rewarding to be part of that.

Sherin Uthuppan, RN

It was such an honor to be able to participate and to have played a part in bringing us closer to the end of this pandemic. I thought it was inspiring how nurses from all different fields heard the call for help and were able to come together quickly to save so many lives. Some were new grads. Some were non-clinical. Heck I’m sure there were nurses who came out of retirement! While working at the clinic, I met a lawyer whose first career was as an RN. He was so happy to finally have a chance to use his hands-on nursing skills for the first time in forever. I thought that was really cool! 

Jesus Chavez-Penaloza, LPN

I enjoyed assisting and getting to know different people from different departments.  I was inspired also by the new administration, to be a patriot and assist teachers, police, and other groups able to come in.  Even the non-clinical volunteers, such as the people who helped to clean those who double-checked the forms were great. I'm a team player and felt the need to assist and keep our associates safe and informed.  I wanted to absorb the information to share with my family.

We encountered challenges, such as when some people did not have access to email to receive a reminder to come in for the next appointment.  I really liked how Dr. Karen MacKinnon adjusted the flow to best serve the community. All in all, it took true team effort to make the clinic a success.  

Lindsay Ruiz, RN

I thought the atmosphere was overall very positive. It was amazing to be able to see people from all over come together for this one initiative. It was inspiring to hear people’s stories of hope and their motivation for getting the vaccine. Despite having some issues with staffing shortages, the volunteers seemed to have great teamwork attitudes and were motivated to get as many people the vaccine as possible. 

Renee Dex, RN, BSN

For me... it was so nice to be a "nurse" again as most of my days spent doing administration tasks. It was important for all of us to be a part of "something bigger" especially since we had been working so hard on COVID-19 clinical studies where we were involved with data collection, treatment protocols, and medication administration since we had returned to on-campus work in May 2020. 

I loved that we were able to meet so many people at MCW and in the community that we would not normally encounter and educate them about the vaccine and its importance. People were so grateful.  

Marking the Moment…and Continuing Forward Together

From the 5/6/2021 newsletter

Perspective/Opinion

Marking the Moment…and Continuing Forward Together

Jennifer Popies, MS, RN, ACNS-BC, CCRN-K; CVICU Clinical Nurse Specialist

Ms. Popies, a Clinical Nurse Specialist in the Cardiovascular ICU, writes about what it has been like to be part of the team caring for desperately ill patients with COVID-19 over the past year. Recently, the caregivers in the unit paused to reflect on the one-year anniversary of the pandemic and to bear witness to what the year has meant …

It is overwhelming, humbling, and simultaneously a source of pride - as well as pain - to think of all the precious nursing moments with patients and families that I have borne witness to or been entrusted with in heartfelt conversation over the past year.  Gestures that may seem like the smallest details of a patient’s care became some of the largest measures of bringing humanity to the bedside.  

Nurses staying in sweltering layers of PPE, including re-used N95 masks for a time, to hold the hand of patients who were scared, alone, and gasping for air. Serving as champions and cheerleaders for patients to encourage them to keep moving, to keep eating, to simply keep trying. Reading letters and cards sent by family members even though the patients were intubated and sedated so they could still have a chance to hear the words of their loved ones. Bathing and washing the hair of dying patients so they would look recognizable for a family’s last goodbye over an iPad. Making handprints of their patients to give to their families to have as tangible memories of their loved one when that is all we could leave them with.  

All roles deserve to be celebrated for their unique contributions to the wellbeing of those we collectively serve, but this Nurses Week, it is a special privilege to try to capture in some small way what it has meant - and continues to mean - to be a nurse in this pandemic.  Never before has the public, and perhaps even some of our healthcare colleagues, really understood so clearly that “Nursing is both a Science and an Art.”  

Deciding to mark our “anniversary” …

Before Nurses Week was approaching, a different date loomed:  March 18, 2021 – the date that marked the one-year “anniversary” of our CVICU accepting our first COVID-19 patient on Extracorporeal Membrane Oxygenation (ECMO).  Our nursing leadership team, along with our ECMO RN Coordinators, talked about how best to honor this. How should we acknowledge the losses our team suffered over the year and the triumphs we celebrated? Most of all, how do we truly recognize and express thanks for the talent, skill, dedication, and compassion of our staff?  

]We gathered feedback from our nurses and settled on brief “marking the moment” sessions - one during night shift at 0300 and another on day shift at 1100 - with a special message read from our leadership team, followed by an even more special compilation of video messages from prior COVID-19 ECMO patients who were successfully discharged from our care.  Then we set about getting the word out about these sessions and inviting all members of our interprofessional team to join in because, as nurses, we coordinate care and our care is not just for our patients, families, and each other, but for everyone on our team.

Hitting the mark …

The date came and, as happens in nursing, we had to adapt our plan slightly from 0300 to 0330 to accommodate a new ECMO patient just rolling in when we initially planned to start. We had to do “repeat” sessions throughout the morning and early afternoon so that we could ensure that all team members working that day could take the time to listen to our message and see the video.  It was worth everything, though, to be able to stand together and pause, to remember together, to tear up and laugh at the video messages together, and to feel the solidarity in our team to keep going, to keep persevering, to keep caring since we all recognize that our work is not over.  

The unprecedented times are not yet done, and we know that our work to share this gratitude for the care that all nurses have given - and continue to give - in every unit, not just ours, is not done.  Indeed, our work to let all our healthcare team members in all departments   no matter their role   know they are appreciated for what they have contributed and continue to give, is not done.  It is in that spirit that I share below a slightly modified version of the message we wrote for and read to our nurses and our team, in the hopes that it will also hold reflection and meaning for you who are reading this.  It is truly meant for each of you, too.

To our nurses and our teams:

In March 2020, when we learned that we would be receiving our first COVID patient at Froedtert, none of us could have fathomed what this past year would bring.  We hear the numbers all around us of what the pandemic has done in America – millions infected, more than 540,000 lives lost - and yet they still somehow fall short of capturing the enormity of what we have personally experienced as a team in just one hospital, in one city, in one state, in one country.

The challenges and changes that we have seen in just this one year are startling to list.  We donned and doffed according to rapidly changing guidelines, we implemented reusing PPE and sending it for UV light disinfecting to try to protect ourselves and each other, and then learned to use other PPE that we had never had to learn before like PAPRs and CAPRs and Elastomeric masks.  We implemented airway teams, proning teams, AGP guidelines, and the use of extension tubing to run IV pumps outside of rooms.  We cross-trained floor nurses and uptrained Resource Pool nurses.  We developed and implemented guidelines for putting patients onto ECMO and other treatments for COVID and adapted them as we learned more with every passing month.  We tried different therapies - hydroxychloroquine, convalescent plasma, remdesivir, and Cytosorb to name a few - all while learning to tolerate O2 sat levels and lab levels we could never previously have imagined.  We adapted different ways to try to help patients handle the symptom burden and isolation of this virus – medication regimens at doses we weren’t used to, partnering with trauma psych despite not being trauma units, learning to use iPads with WebEx for everything from routine family connection time to family conferences to harps of comfort music sessions to end of life moments.

Specific to COVID-19, we have collectively cared for hundreds of patients.  We have lost some of these patients, despite our best efforts, despite exceptional care, despite our deepest hopes to give them back to their loved ones...but these efforts were not in vain simply because they died.  Their families noticed, their communities noticed the care they received, and we will remember them; caring for them changed us.  Please join me in a moment of silent remembrance for them now...

We have also been able to celebrate incredible triumphs, moments of seeing our patients stand for the first time in many weeks, be freed from their tether to an ECMO machine or a ventilator, roll out of our ICUs to other floors or facilities or home with us cheering them on.  None of that would have been possible without each of you, without each member of our team, whether your role was directly caring for COVID patients or caring for our other acutely ill patients who required our specialized care.  One shining, crystal clear truth that has never changed over the past year is this:  When we stand together, we stand stronger - for our patients and for each other.  

As a leadership team, we have marveled at what has been accomplished this year and are incredibly proud of the care you have delivered and continue to deliver despite personal struggles and the professional challenges that have been faced.  There are simply not enough words to express our gratitude, our deepest thanks for everything that you have done and who you have shown yourselves to be as the Froedtert team in caring for all the patients and families that we have served over this past year.  Please know that you are seen, you are valued, you are our Froedtert Family!  Thank you from the bottom of our hearts!

Jennifer Popies, MS, RN, ACNS-BC, CCRN-K is a Clinical Nurse Specialist in the Cardiovascular Intensive Care Unit at Froedtert & the Medical College of Wisconsin.