C-suites, clinicians are burning out at both ends

C-suite leaders and clinicians often feel they are on opposite sides of an ever-expanding chasm. But they actually have a lot in common, according to Bruce Cummings and Paul DeChant, MD — a former executive and a former practicing physician, respectively, and perhaps an unlikely pair. 

Executives and physicians are both knowledge workers. Both are trained to spot and solve problems. Both crave the autonomy to fix those problems — but often, neither feels they truly have it. Both are far strides from the bright-eyed, difference-driven graduates they once were. 

Both are exhausted, and neither really knows how to talk about it. 

This conversation is the mission of Mr. Cummings — a 40-year health system executive who served 27 years as a hospital CEO — and Dr. DeChant — a family medicine physician for 25 years turned clinical executive, and a former CEO of Sutter Gould Medical Foundation. They now collaborate as co-founders and principals of Organizational Wellbeing Solutions, working with hospitals and health systems to transform administrator-clinician relationships and address burnout. 

Mr. Cummings left retirement for the cause, concerned that his "former colleagues, fellow CEOs around the country, were kind of missing the boat on burnout."

"I want to spread the gospel that the cause of burnout is the workplace. It's not a lack of resilience on the part of the workers," he told Becker's. "And that includes, by the way, executives, many of whom are now at burnout rates that are pretty close to those of physicians and nurses."

The B-word and its roots 

What, exactly, is causing executives to burn out? One contributing phenomenon is what Dr. DeChant calls "administrivia": an inundation with data tasks. 

"The typical executive feels he or she is just being inundated with emails, phone calls, meetings. There's just an incredible demand for attention and so little mind space to deal with a myriad of issues," Mr. Cummings said. "Physicians wrestle with this, too. They are unable to do what they've been trained to do and make decisions in the way they would like to make them. They don't always have the level of agency or autonomy that they feel they should have. And that in itself creates a kind of psychic distress or moral injury as some refer to it." 

This is not a novel complaint. In fact, with the rise of artificial intelligence, it is one that more leaders have taken action to address. Automating administrative tasks can improve efficiency and give caregivers more time with patients, which can reduce burnout — but it is unlikely to eliminate the problem. 

Even if email shut down for a day, executives and clinicians are "under tremendous pressure to perform," Dr. DeChant noted. 

"A CEO has got to perform for their board; they have a dashboard full of metrics to achieve. They've got a community to provide care for, and they've got more than just the doctors to worry about," Dr. DeChant said. "Meanwhile, physicians are under pressure to be far more productive than they have been in the past and to meet a myriad of expectations that help drive dashboard metric success." 

Both parties are bound to the same numbers, but often neither fully understands the constraints and frustrations of the other. Mr. Cummings and Dr. DeChant disagree on how challenging the CEO job was two decades ago, but they concur that it is "nearly impossible to do now." 

And medical schools are not like business schools, Dr. DeChant said: "They don't really talk about the cost of anything." In medical school, the goal is to do everything possible to care for a patient — regardless of time or resources. In the increasingly corporatized healthcare industry, that is not a reality. When physicians contract with a health system and no longer have the autonomy they had in private practice or that they were promised in school, tensions can rise. 

"Control goes very deep for physicians because we spend a decade of our 20s — when most of our friends are out building their families, building their careers, partying, having some fun — we're simply going deeper into debt and working 80 to 100 hours a week to get the knowledge and skills we need so we can take control when people want us to," Dr. DeChant said. "And then when that gets yanked away in the real, harsh reality of the first job, that goes deep. It's one of those examples of absence of fairness."

"Absence of fairness" is one of six burnout drivers defined by researchers Michael Leiter and Christina Maslach (who in 1981 pioneered the Maslach Burnout Index, the first scientifically developed burnout measure). The other five drivers are work overload, lack of control, insufficient recognition and reward, breakdown of community, and values conflicts. 

Where these drivers are present, workers are prone to burnout, which might show up in three dimensions: exhaustion, cynicism and decreased professional efficacy. 

Based on these criteria, burnout in healthcare is inevitable. Work overload is common in today's understaffed, overcrowded hospitals. Medical outcomes are impossible to fully control and are not always ideal. Rewards and recognition — at least as far as the public is concerned — are tougher to come by as Americans' trust in healthcare wanes. Values conflicts will exist to some extent as long as services cost money. 

And when burnout hits, vital dashboard metrics begin to slip. Cynicism can creep in as performance falters. The rift between C-suite leaders and executives is more likely to grow, and the final driver appears: breakdown of community.

"What was before kind of a simmering tension just born of our different training and perspectives has become this huge chasm and this tremendous tension," Mr. Cummings said.

If that tension is contributing to the burnout cycle, is the solution for one party's burnout dependent on the solution of the other's? 

"That," Mr. Cummings said, "is a beautifully loaded question."

What works 

"There is a way forward," Mr. Cummings said. "But it requires a wholesale reconsideration by the executive suite in the way they relate to physicians."

Specifically, Mr. Cummings and Dr. DeChant encourage their health system clients to change the way they gather information. Rounding is popular — and well-intentioned — but it does not always lend itself to transparency. 

"When I was a practicing physician, when that kind of rounding would happen, I'd be busy working away and I'd see a group of executives coming down the hall," Dr. DeChant said. "I knew instantly I had two choices. When they ask me how things are going, I could lie in an effort to try to not get further behind in my schedule than I already was. Or I could tell the truth and get 45 minutes further behind." 

By trading rounding for shadowing, leaders can alleviate the pressure front-line workers feel to give intentional feedback while on the clock. They are more likely to witness issues firsthand if they spend a full day on one unit, gauging one perspective. And they should be mindful, Dr. DeChant said, that "no one likes to give bad news to the CEO." 

The pair also encourages health systems to hold routine meetings between practitioners and C-suite leaders. To get the truth, they should hear directly from front-line workers, not just their department heads or division chiefs. 

"As executives, how we typically get information is [it is] aggregated and it bubbles up to us, right? We're on our computers, we're looking at spreadsheets. We're getting reports from our vice presidents, who are in turn getting advice and reports from their directors or assistant vice presidents. Directors in turn are getting information from their managers and so forth," Mr. Cummings said. "It kind of bubbles up and by the time it gets to the C-suite, it loses its luster, the rawness. It's just divorced from what's really happening on a day-to-day basis." 

The more time leaders spend information-gathering outside their offices, the less all-consuming the dashboard feels. Executives might find a renewed sense of purpose — and clinicians might see more creative solutions to the problems they face, but are not always able to articulate. 

Finances as 'the trailing metric'

A tough truth to swallow: Even if leaders do shadow and host listening sessions, they are unlikely to fully grasp what physicians and nurses are going through — even if they were once practicing, too. 

Christopher Lehrach, MD, chief physician executive at Danbury, Conn.-based Nuvance Health, noticed that even before COVID-19, levels of self-described burnout on employee and physician surveys were "unacceptable." But from the outside looking in, it did not really add up. 

"There was a discordance for me between what the scores were and what I was experiencing moving around our health system, because this did not feel like a group of people who were all who had lost faith," Dr. Lehrach told Becker's

He had experienced "low-level" burnout himself as an emergency room physician for 25 years and was interested in treating the issue holistically: "not just blaming the victim by giving them resiliency training and ways to help manage the downstream effect of a very difficult healthcare system [generally speaking]." 

"I was really interested in going upstream and trying to figure out what is it about the culture of the organization, the leadership and their influence, the priorities, the language? And what is it about the workflows and how folks are toiling every day in their environment that's become so untenable that people are considering leaving the organization — or, as the data would suggest, dying by suicide at four times the national rate? Those are really horrific numbers."

Dr. Lehrach connected with Dr. DeChant and Mr. Cummings, and they began working toward change. First, there had to be a shift in the language used by leadership. Discussions about finances needed to become discussions about purpose, even if finances were still critically important to the C-suite. There is a trickle-down effect, Dr. Lehrach said. If staff feel respected and like a true asset, they provide high-quality care that delights patients. 

"Finances will be the trailing metric, and we won't have to spend as much time talking about them," Dr. Lehrach said. 

To foster that language shift, the right people have to be in the right positions. Dr. Lehrach emphasized that he was not the change agent in the system's efforts to reduce burnout. Rather, intentional recruiting was. The system looked for leaders who had a deep sense of compassion and empathy for one another and had the capability to "change the tenor." It elevated clinical voices through listening sessions, which has improved the front lines' agency and morale, and the C-suite's ability to knock pebbles from shoes. Leadership lets the front lines set priorities, then tackles them. 

Whenever possible, the system promotes leaders who are "bilingual" — with both business and clinical experience — into leadership positions. And it has identified two system wellness officers who have assumed more of the traditional burnout work, such as peer support and resilience training. 

One last requirement of a culture shift: Everyone has to be on board. 

"I do think culture starts at the top, and if you have members of your team who are unwilling or unable to embrace some of the changes that we've talked about … if you can't change the people, I think you've got to change the people," Dr. Lehrach said. "I think it's that foundational to the health of the healthcare system. And that isn't necessarily popular because they can be really effective subject matter experts and really effective leaders. But this is a core competency from my perspective."

Using these methods, Nuvance has been able to "dramatically" improve its scores on all nine realms of its clinician satisfaction survey, he said. 

High stakes 

The conversation around burnout has been accelerating, but it is not yet "kitchen table talk," Dr. Lehrach said. Families are trying to get their kids to school and pay their mortgages; they are not concerned about the lives of executives and physicians, usually a financially privileged class, he added.  

"There's still this reputation that doctors, you know, take Wednesdays off to play golf and drive Mercedes," Dr. Lehrach said. 

But it is important to understand how burnout in health systems will affect everyone; as an industry, a neutral stance on this issue could cause a landslide. 

"The endpoint impact of burnout in clinicians — which we saw exacerbated during COVID — is earlier retirements, reduction in [full-time equivalents], [clinicians] going into administrative roles, leaving clinical roles, not entering medicine in the first place, or the worst result is death by suicide," Dr. Lehrach said. "It's really worrisome. 

"You're seeing the overall capacity decline, and so that's going to lead to access issues. There are already access issues. Every family knows that —  try and get a new appointment with a primary care doctor. I think it's the access issues that are the result of burnout that are going to make it that kitchen table conversation because now you're going to have delayed care, chronic illness, costs are going to go up, people are going to get sicker." 

"I think the thing that we're not having a national conversation about is the access issue that's resulting from this." 

Read more about physician burnout and its effects here. Read more about the silent stress of executives here.

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