Wayne Jonas, MD

 This month at Physicians Practice, some of our contributors are focusing on the topic of burnout among physicians and staff.

Self care is of critical importance for physician and during the pandemic, self-care took on a whole new level of importance for providers, especially those on the frontlines.

Today, you will hear my conversation with Dr. Wayne Jonas, executive director of Samueli Integrative Health Programs, as we discuss the rise of burnout among physicians and staff both during and just prior to the pandemic, and strategies for reducing burnout in these populations.

We began by addressing why burnout remains such an important topic.

 We were already having trouble with burnout before the the bomb was dropped on the world with the COVID pandemic. You know, many of the frontline people, intensivists, emergency room, physicians, primary care physicians, and others were approaching 40% to 50% criteria for burnout. So, we already had a challenge in the system in dealing with burnout. And I think now with the rapid change that's going on—with sort of the implosion of the economy with the decline in, in both revenues and the capability of doing even basic clinical care—that has just exacerbated the change on top of this. So it is extremely important that we up our game in burnout prevention and management. And so you know, your questions are very appropriate for these areas.

I mean, the reasons for avoiding burnout have been very well delineated. The National Academy of Medicine did a major study on it published last year, American Academy of Family Physicians made it their theme over the last year on physician well being. And so the reasons for those are well known.

You know, with burnout, we have reduced empathy and the ability to actually provide care and a part of healthcare. We have less responsiveness to the needs of patients, and we pick up less on what's going on and therefore we're less accurate in our diagnostic and treatment decisions and capabilities. Trust gets eroded, there's an increased chance of error and mistakes and therefore harm in these areas. And now, if you pile on top top of that, the economic stresses that are occurring both for those in practice as well as for our patients, you know, we've got we've got a problem.

 One of the first steps in reducing burnout is to address that there is in fact a problem. However, bringing up these topics might be erroneously perceived to be admitting a weakness—there is a stigma attached to addressing or admitting burnout and fatigue.

Those in the healthcare industry will need to find a way to get around this stigma in order to begin addressing and solving the burnout plague.

 Stigma is a huge thing. I mean, as physicians know, if you cover up an illness that is ongoing, and don't take steps to catch it early, treat it early prevented, it's going to be a much bigger problem later. And that is the situation with burnout—if you if you put a blanket over it if you pretend that it's not there, if you don't address it. And stigma is one of the ways that keeps us from addressing.

I worked a lot with I might a good part of my practice was in the military, I was in the military for over 20 years, I still see patients in the military. There's a lot of parallels between what's going on now, in terms of frontline, crisis related medicine’s huge changes and what was experienced in the military with PTSD and moral injury. The military, I think, in many ways, like physicians, are tough, right? They're there to do a job, they don't want to show weakness. they want don't want to show ignorance, they don't want to show that things are slipping or they can't deal with the situation.

So the first thing is to acknowledge that there's a lot of changes going on. And really everybody is experiencing stress. And whether you can meet some criteria of burnout on a test or not, is irrelevant. The issue is if you're feeling in fact that your ability to function at your optimal is less, then it's likely that you're experiencing this and you need to open up and acknowledge that you need to say, I’m vulnerable here, because I'm a human being, and I need assistance in coping with this type of thing.”

And when leaders in the military came forward and admitted that, generals, for example, said “Hey, I'm experiencing this too”, that helped reduce the stigma. And so, physicians need to be able to also say that so they and their colleagues can address this importantly,

 Up next, Dr. Jonas explains the signs that physicians should be looking out for in themselves and coworkers to more readily identify symptoms of burnout.

 Yeah, well, there's a number of signs and these have been pretty well delineated. Again, I've seen it in military populations, but the National Academy and others have delineated this as well.

They largely fall into four major categories, some objective and subjective ones. The behavioral and objective ones are the ones that are the most telling—things that you can see in others, and if you see them happening in yourself. Things like: lack of sleep or difficulty in sleeping, waking up or difficulty going to sleep, a sense of apathy and finding yourself isolated from your colleagues or your team, not engaging in the normal type of social contact that you would have with others, being reactive, finding that you're more irritable than usual and that you're responding to small things in ways that you would normally just let a roll off, or even crying or actually feeling despondent or isolating yourself in those situations.

There's emotional issues: anxiety, fear, and anger are major signs of that. There are cognitive issues: difficulty concentrating; or in some cases, over analysis of a situation that you would normally be able to solve and wouldn't be a problem for you, but now you're thinking it through and you can't make decisions, et cetra. That can be a sign of burnout, as well as physical symptoms: increased pain, fatigue, just feeling tired, being depressed. Those are all signs that burnout is creeping up on you or has gotten a hold of you and it's time to take action.

 If you notice any of these symptoms in yourself or colleagues, Dr. Jonas says there are a number of ways the reduce burnout. He says that one of the more successful interventions of his team is to model self-care dialogue among team members.

 it's very important that you pay attention and support your colleagues during this period. One of the things we found to be most useful in managing burnout among our team is realizing that you're not alone with this. In essentially communicating when you see these kinds of signs in your colleagues to say, “You know, I'm experiencing this, are you experiencing this?”—that type of ability to dialogue in this area not only opens you up to a dialogue, but it also helps your colleagues in these areas, being in your own huddles with your team, acknowledging that this is happening, and that self-care and the need to address it is there.

So, modeling It is really, really important. I think once that's acknowledged modeling the self-care components, not only acknowledging it, but a number of self-care components that can help blunt mitigate or reverse it are key,.

Physicians tend to feel like they should have all the answers and they should be able to address every problem. And this is one of the major aspects. And you can't do that in times of very rapid change.

So, I just did a whole set of group visits for my chronic pain patients this morning. And man, I did not deal with the technology, okay. And we were having issues there. We had a guest that was coming in to help build skills in their chronic pain management. And so, I'm learning, and I had to acknowledge that right up front— I can't do everything in these areas. And so, my team then becomes really, really important. I have health coach, coaches and health navigators, Behavioral Medicine folks, pharmacologists—I need to bring them into the support structure so that I don't feel like I have to do all. Delegate in these areas. I think a third thing that'd be two things very important to do.

The third thing is that. As we used to say in the military that the best laid plans were the ones that had to be changed as soon as you met the enemy. That doesn't mean you don't do planning, but it means you realize you have to have flexibility because it's not going to go as planned. Okay. And this certainly hasn't gone with plan as we've gone through this particular pandemic. And so, having the flexibility to realize there's going to be changes and its okay, let's adapt to that. It’s really, really important to take breaks, personal breaks, self-care breaks. One of the big challenges my chronic pain patients were having this morning on our group visit was balancing activity with overactivity. If they did too much, they would get pain. If they did too little, they wouldn't actually improve their pain. It's the same thing with our life—you have to be able to take care of yourself, to heal the healer, if you're going to be able to actually take care of others. So, self-care and self-care skills, then, become extremely important. You need to take the breaks and, in those breaks, do things that refresh you and rejuvenate your mind-body practices to reduce stress and relaxation. Exercise is extremely important for managing stress and burnout. Social connectivity, not just social connectivity with your patients, but with your family, with your friends, with your colleagues, things that you enjoy doing, looking for what matters in your life, and making sure you get some of that regularly every day.

I would say that that extremely important thing that is not really understood, is the mindset. So, there's been excellent study showing that the mindset that you go into managing stresses with can make a difference as to whether you come out stronger on the other side, or whether it becomes burdensome research at Stanford and others have shown that if people see stress as a way to grow as a positive thing, then in fact, they will respond in a much more positive way. And it can give them energy, if they see stress as a burden, as something that is just going to weigh them down, then the same stress is going to produce two completely different responses. So, resilience is not about getting back to the way you were we're never going to be back exactly the way we were after this pandemic. But it's about learning adapting and growing. And the mindset that you go into it has is much more powerful than than we in the in the medical sciences are usually willing to acknowledge.

 The additional challenge now, will be how to implement Dr. Jonas' tips into the busy life of a healthcare professional.

 You know, that's an interesting question. What do you do with less time? Well, if you and then the second question is, do we really have less time?

But if you have less time, then it becomes really important that habits that are involved in self-care are built into the little amounts of time that you have. So, mind body practices, mindfulness-like practices, you know, in the old days, you might take a mind body course, and you go to eight weeks, and you would learn how to meditate 20minutes every day, and all that kind of stuff. You can't necessarily do that all the time. But what you can do is you can take some of those kinds of skills, and there are some of these on my website to help you do this in a more in an efficient way. You can take a breath, you can take a perspective, you can create a mindfulness bubble, if you've practiced it, okay? It's very easy to stay fit if you stay fit on small, regular activities, right? It's the same way with mental fitness. If you engage in periodic small, five-minute kind of mindfulness types of things, breathing exercises, that builds up areas in your frontal cortex that make it easier than to do that when you don't have time to try to do that. They've shown for example, in the area of burnout, which this is about that simply taking a few minutes at the end of every day and reflecting back on what has happened today that you are grateful for. What's something that gives you gave you joy that gave you connection, that you said, “You know, I loved this or it was a wonderful connection”, or “This good thing happened to me”, or “I'm alive in those areas.” Simply a five-to-10-minute reflection everyday can have marked impact on burnout if it's done regularly as part of the habit. So, I would say that time issues is embedding it in your habits taking it in small pieces, gratitude Exercise is mindfulness. And then if you have more time take advantage of those of those times to do the kinds of self-care, organizational things that you would do anyway.

 Telemedicine, the popularity of which soared during the pandemic, also poses new risks for physician burnout.

 I think most of the physicians that I'm talking to and teams I'm talking to, and in my own practice I'm experiencing this myself, is it's a very double-edged sword. And until we learn, you know how to take advantage of the advantages in managing challenges, it's going to be anxiety-provoking, I think the biggest problem of the biggest fear on telemedicine is the demand on time. Because now, it's not simply me going to the office and you're scheduled and I see you now—it can happen any time. Patients have access to me, I have to access them, they come to me in my home where I am right now, I go to them in their home. So that is the big worry, that has to be managed.

But the flip side of that is flexibility. Okay, now I can actually schedule my visits in between bathroom breaks, or in between some interaction with the family or doing something else that's in my in my home that I need to do to take care of my life, between exercise and so I actually may have more time to do this. Now suddenly, I'm making home visits and learning a lot more about my patients, instead of having them coming in and telling me this is going on not really knowing that it's actually like in the old days, when I actually used to actually do regular home visits. And I'd see what's happening there and to help them get better with their safety issues with their behavior and lifestyle with their social issues in those areas. Now, suddenly, I'm in their home, you know, we know that the determinants of most health, chronic illness, for example, our underlying lifestyle, the things that impact the bread and butter of what goes on in chronic disease, heart disease, diabetes, obesity, hypertension, etc, 60 to 70% of these have to do with behavior. It's not simply about pills and procedures, or the social determinants of health, the poverty, the stresses that go on, suddenly, we're out of the office in their homes. And so there's an opportunity, if we take the flexibility to actually more thoroughly and more holistically evaluate and care for our patients than we used to. And so, threats by demand on our time, but flexibility on the other hand, and I think where it pans out depends on how we manage it.

 Up next, Dr. Jonas offers some final parting words of advice.

 Well, I think, you know, on my website, I've put together a whole set of tools, my team has to talk about how you manage burnout in these areas, excellent lectures, that we've made freely available from folks from around the country, on how to manage burnout. So, if people want to get into the more details of this, how to protect yourself, how to enhance your immune system in those areas, and how to have a more comprehensive, whole person integrative dialogue with your patients. And I would say, if there's anything that you need to do with this pandemic, once you've gotten through the major changes that it's causing, is take advantage on building your practice in a way that is more comprehensive, more holistic, and is more effective in addressing the underlying determinants of your own health and the health of your patients.

Podcasts

Physicians Practice® spoke with Dr. Wayne Jonas about the rise in reported burnout among physicians, especially during the pandemic, and how the industry can work to overcome stigmas and begin to address these issues. 

Combating burnout in physician practices

Telemedicine has proven to be a double-edged sword, says Wayne Jonas, MD. Until we learn how to take advantage of the benefits, and manage the challenges, telemedicine will be anxiety-provoking.

Videos

Until we learn how to take advantage of the benefits, and manage the challenges of telemedicine, it will be anxiety-provoking.

Telemedicine may pose new threats for physician burnout

The pandemic has left some physicians with more time due to fewer patient visits; however, for the physicians in the ‘center of the storm’, mindfulness and mind-body practices are very important for building a resilience to burnout with less time and increased stressors, says Wayne Jonas, MD.

Mindfulness and mind-body practices are very important for building a resilience to burnout. 

How physicians can manage burnout with less time

If you cover up an ongoing illness, it will be a much bigger problem later—that is very much the situation with burnout, says Wayne Jonas, MD.

Here are some ways physicians can reduce stigma of discussing burnout to start to recognize warning signs and reduce the impact on themselves and colleagues.

Reducing burnout discussion stigma

Existing challenges in addressing burnout have been exacerbated throughout the pandemic, Wayne Jonas, MD, says. We need to up our game in burnout prevention and management.

Why burnout remains an important topic during the pandemic

The COVID-19 pandemic will change our medical practices forever, in ways we cannot even yet imagine. I was doing telemedicine before the pandemic but now practically my entire practice is remote. Often this works well, but sometimes this does not work well at all. After this crisis is behind us, we will all have the opportunity to rethink how we do our daily work. For me, it will be focusing more than ever on the power of integrative health to assure greater wellbeing for all of us in ways that might help protect us from future health calamities.   

For 40 years, I have studied how to get healing back into the heart of medicine, and I believe reinventing our medical practices can serve our patients more fully in the years to come. Our focus must not just be on treating illness but also integrating health promotion and prevention through self-care into the treatment of disease. We must be prepared for a value-based system that will reward us for the quality rather than the quantity of care we provide our patients.

Improved technology, expanded access, and better collaboration within healthcare teams all reinforce this change. Far more important, however, is the potential to rethink the very nature of care by aligning with the extensive evidence supporting reliable, cost-efficient forms of treatment that extend beyond pills and procedures and beyond the office walls.

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Research has repeatedly shown that even with full medical access, a population’s health improves only by about 15 to 20 percent. Our overall health and wellbeing overwhelmingly comes from behavior and lifestyle, the local environment, and the social determinants of health. Thus, 80 percent of health is determined by factors outside the hospital and clinic. This is also true during pandemics where social distancing and hand washing (all done without a doctor’s help) are crucial to preventing illness and death. 

More than half of the top 25 chronic conditions (hypertension, diabetes, obesity, chronic pain, anxiety, depression, etc.) can be mitigated and treated effectively with behavioral and integrative health approaches including, nutrition and movement, stress management, sleep, social support, and evidence-based complementary medicine such as therapeutic yoga, acupuncture, and massage therapy. These approaches are far less expensive than drugs and surgery if applied in time.

How can physicians align their patient visits to produce health? 

I have seen positive results in my own practice by utilizing new ways of treating patients and seeking reimbursement to cover such approaches. I know from experience that we can restructure our office visits now to reframe the patient experience from one focused exclusively on diagnosing and treating disease to one that personalizes care and emphasizes prevention, health-promotion, and self-care. We can shift to integrative health. In the process, we can rediscover the satisfaction of feeling that we are not just treating illness, but helping my patients heal. 

In medical school, we all were trained to employ the SOAP note (Subjective, Objective, Assessment, and Plan) and use it to chart a patient’s condition and treatment. This methodology-and the current payment system-sharply limits the ability of physicians to make healing their primary mission. So, I supplement the SOAP approach by adding what I call a 

, which stands for Healing-Oriented Practices and Environments. This is a quick and straightforward way to align what is most important to the patient and address their underlying determinants of health. Understanding what motivates a patient is key to encouraging their ability to change behavior. 

Fundamentally, instead of only asking my patients 

 I attempt to get to the root of their health and wellbeing needs by asking, 

. The HOPE note process is a tool for delivering value-based care by caring for the whole person. It has helped me learn to listen more closely to my patients, to better understand the underlying drivers of what may be making them sick, and to help them choose their best personal path to healing. Knowing what their main drivers of behavior are (what matters) helps even in epidemics as it allows you to meet them more authentically, helping them to better balance personal wants with medical needs.

How can physicians bill differently in the new payment models?

We’ve long known that lifestyle changes can help manage depression, hypertension, diabetes, and other chronic ailments. With the changes in Medicare, healthcare providers need to be thinking about ways to both promote health and capture those changes to benefit from value-based billing models. We know that a properly delivered annual wellness visit can be used to explore and personalize what a patient wants and needs.

If an office organizes its health payment coding properly, providers can get paid for team-based care that includes helping patients in behavior change and health promotion. There are an increasing number of codes for the Annual Wellness Visit, the Welcome to Medicare, and codes for weight management, hypertension, diabetes prevention, mental health conditions and chronic pain thatâ¯can be used to cover discussions aligned with and following a HOPE visit.

It is good to remember that many outpatient evaluation and management visits can be billed as counseling and coordination of care. Group visits (and increasingly virtual ones) can be particularly rewarding to lead-and they benefit the practice-by allowing us to briefly see each patient and document the visit in the chart. CMS is rapidly loosening restrictions for billing by telehealth because of COVID-19 so enhancing your billing practices for virtual visits can help pay for your time. 

In value-based payment models, health-and-well-being service lines earn essential

points Patient-Centered Medical Home designation by the National Committee on Quality Assurance (NCQA) and provide a new angle to improve outcomes in pay-for-performance systems such as MIPS (Medicare’s Merit-Based Incentive Payment System). 

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However, demonstrating these outcomes requires more than just coding. Designing a practice that tracks improvements in health for patients is essential. Physicians can enhance their billing code process and gather data on patient needs that aligns to a value-based, patient-centered model.

Finally, how to bill and get reimbursed for the underlying social determinants of health has always been a challenge in primary care. While today’s reality looks different than it did a few months ago, we must still embrace the value-based model and take advantage of the billing change that’s coming. Indeed, the growing number of people losing their jobs and health coverage with the national shutdown is only increasing the numbers who need support for their social and economic determinants of health. More effectively and efficiently dealing with the personal determinants of health will ultimately enable us to listen to our patients and address their issues holistically. Now more than ever, we need to care for patients in body, mind and spirit. 

 is the Executive Director of Samueli Integrative Health Programs and the author of How Healing Works. Prior to this role, he was the Director of the Office of Alternative Medicine at the National Institutes of Health and served as the Director of the Medical Research Fellowship at Walter Reed Army Institute of Research. He is also a Clinical Professor of Family Medicine at the Uniformed Services University and at Georgetown University School of Medicine. 

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And other strategies to refresh your practice.