If we are serious about improving doctor wellbeing at work then it’s time to start looking beyond individual interventions and thinking about what we can do at an organisational level.
As a workforce, doctors are struggling. High rates of burnout and mental health disorders are reported in Australian doctors and burnout is estimated to occur in more than 50% of doctors in the US . Not only is this problematic for individual doctor wellbeing, but it threatens the quality of patient care. And let’s not forget the ongoing tragedy of doctor suicides.
In response to this things are starting to change. Programs are proliferating focusing on teaching skills like mindfulness with the aim of building resilience. There are such programs popping up in all sorts of places – medical schools, hospitals, local health districts.
These are useful and needed – but evidence shows relying on these programs alone is unlikely to do more that scratch the surface of improving wellbeing in clinicians. A ‘recentish’ Cochrane review concluded: “There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions.” And, as one author noted recently, each new program that pops up reinforces the implicit message that somehow doctors are responsible for their own suffering. Ironic, given the rigourous nature of medical training and medical practice, a strong case could be made that doctors are more resilient than the general population in any case.
So what’s the state of play in improving clinician wellbeing?
Programs such as mindfulness based stress reduction are common – and hold promise. Without an in depth review of methodology, here’s a snapshot of some current research into individal approaches to clinician wellbeing:
- An RCT of a mindfulness training in 44 Australian interns showed: “participants undergoing the 10-week mindfulness training program reported greater improvements in stress and burnout relative to participants in the control condition”
- A cross-sectional study of 672 primary care physicians suggested: “that interventions focused on improving mindfulness and resilience may be helpful in the prevention and treatment of burnout”
- An RCT of a mindfulness based stress reduction program conducted over a year in 42 physicians showed: “sufficient evidence to suggest that the mindfulness-based training program was an efficient intervention to enhance relaxation states”
- A meta-analysis of 12 studies involving 1034 participants suggested: “that cognitive-, behavioral-, and mindfulness-based interventions focused on stress reduction significantly reduce symptoms of anxiety in physicians”
So setting aside the statistical fancy footwork in assessing the methodological quality of these studies and hence generalisability it does seem that these types of approaches are of (at least some) benefit.
Nevertheless, there is now growing recognition that if we want to improve wellbeing in doctors we need to do something beyond the individual and start thinking about what we can do at the organisational level.
What about organisational approaches?
A whole range of organisational approaches have been reviewed when it comes to promoting wellbeing at work. One such strategy it’s worth taking a closer look at is leadership development given there is growing evidence that leadership style can have a positive impact on employee wellbeing in the world at large. So too in healthcare there is an emerging literature that transformational leadership style can result in improved wellbeing and reduced burnout.
Two literature reviews (in the US and Mexico) have shown a transformational leadership style was linked to improved clinical staff wellbeing and reduced burnout in healthcare systems. A survey of nearly 4000 US physicians showed a correlation between transformational leadership and reduced burnout and improved satisfaction. Most recently a study showed that transformational leadership styles increased happiness at work in a group of Spanish physicians. While positive, this is only a small number of studies it must be acknowledged that this is only a small number of studies. Many more studies have been done in other work contexts across the world.
The good news is, that transformational leadership (see box) can be learnt and taught – and leadership coaching is a useful and effective methodology that has been trialed in Australian healthcare settings.
Transformational leadership is an engaging and motivational style of leadership that comprises 5 broad behavioural elements:
And the really neat thing about coaching is at least one study has shown a ripple effect of benefits beyond the person being coached to have a positive impact on the people they interact with.
No doubt a statistician or methodologist will show these studies looking at the impact of leadership on wellbeing are beset by the same small sample size problem etc found in the individual studies.
But, I put it the world at large, doesn’t the presence of even weak or preliminary evidence means these strategies are worth trying given the very real problems we are facing with the health of our clinical workforce. Who knows – perhaps the additive effect of leadership training and individual approaches will boost each other for a much larger effect.
We know that there’s a perception that leadership development is around 10-15 years behind the corporate world and there’s a void in physician leadership training in medical education in general. As early as 2003, Australian authors were suggesting initiatives focused on leadership would likely have a bigger impact on wellbeing in clinicians than individual approaches. And yet, in 2017 we aren’t that much further ahead. What we know about the impact of clinician leadership on staff wellbeing is just the tip of the iceberg.
Much work needs to be done here. It’s time for us to catch up and start testing and, dare I say, implementing a whole village approach to raising clinician wellbeing.