My dad walked into the waiting room to greet his next patient and made a bad pun (is there any other kind?) about the patient’s name. I rolled my eyes, but people loved it. Their doc knew them well enough to joke around with them. Relationships are essential to healthcare. For patients, caring relationships create comfort and safety interacting with the care team, disclosing sensitive information, or starting a new treatment. And for clinicians and care teams, relationships create meaning and a feedback loop to help them know they’re making a difference in people’s lives.
Relationships sustain us. No one thrives in a transactional world. Yet so many aspects of healthcare make patients and clinicians feel like cogs.
Many discussions about burnout and moral distress have moved beyond each clinician’s personal resiliency to ensuring mental health care is easier for clinicians to access, and to the underlying structural and systemic causes: dysfunctional or toxic work environments, loss of autonomy, and the lack of time to create trusting relationships with patients.
At this year’s American College of Physicians (ACP) conference, many sessions were devoted to organizational culture, leadership, empathic connections, and professional fulfillment. Dr. Elisabeth Poorman spoke about her experience seeking mental health care during her residency, and how she began to collect stories of the challenges clinicians and clinicians in training face when they try to get help. For example, often, the person who is triaging medical residents for mental health care is the same person who evaluates residents professionally. So, there’s an inherent confidentiality issue. Changing this process is one way to create psychological safety so clinicians can have a conversation where it’s okay to disclose burnout or mental health problems.
Another strategy is putting opt-out therapy appointments in place. When a clinician starts a new job, default therapy appointments are already set up unless they proactively cancel them. This normalizes mental health care. And anyone who has already been suffering doesn’t have to spend time and emotional energy finding a therapist and scheduling an appointment. Dr. Poorman noted that when opt-out appointments are put in place, most clinicians don’t opt out.
There also needs to be a complete team to support patients. As Dr. Poorman explained, caring physicians want to be there for people and help address upstream issues like poverty, incarceration, and drugs; but they aren’t trained to find food pantries. Yet many social workers have been eliminated — leaving a gap. This gap often creates a sense of futility, and an ethical and moral dilemma. As one physician wrote, his own burnout was a result of “..feeling that I do not have the time to make the number of right and safe choices for my patients, or respond to the amount of care that they need in a given day.”
Relatedness: Creating a 3rd Conversation
While the pandemic has brought the public’s attention to clinician burnout, few are aware of how prevalent it was before Covid, and how many other issues contribute to it. So, while clinicians talk with each other about their exhaustion and challenges, and patients talk with each other about challenges navigating a fragmented system, an effort to bring these stakeholders together to talk with each other to create bi-directional empathy and compassion is: 3rd Conversation.
It was co-founded by consumer advocates Jennifer Sweeney and Christine Bechtel, and physician and community organizer: Dr. Andrew Morris-Singer. Jennifer attended an ACP luncheon where she heard clinicians talk about their own suicidal ideation. She recognized the same frustrations patients have: feeling disempowered and unsupported. The group asked themselves:
- How can patients and advocates have a meaningful impact beyond Patient and Family Advisory Councils?
- What do patients know about clinician well-being?
- And what would happen if patients and clinicians came together to talk about their experiences receiving and giving care?
Working with a narrative medicine expert and a facilitator skilled in high-heat discussions, they created a pilot where physicians, nurses and other clinicians sat down to have one-on-one conversations with patients. Within 5 minutes, they saw people listening intently.
These are called “Spark” experiences. Each Spark experience is about two and a half hours, with about 26 participants and a professional facilitator. They’re currently held online, and plan to return to in-person in the future.
The conversations are eye opening and therapeutic for everyone. They’re a chance for patients to see “backstage” and learn what the system and experience is like for clinicians. They find they’re allies – and patients learn they’re the reason clinicians show up and find meaning in their work, and not the cause of burn out. Clinicians also gain insights; for example, that patients sometimes hold back information because they don’t want to be a burden. Participants feel heard and often realize they have shared values and want to advocate for the same things.
In 2019, the 3rd Conversation held interviews with organizational leaders, most of whom were also clinicians. Many leaders expressed feeling like they have a target on their backs, that they struggle to make difficult tradeoffs, and often feel their hands are tied regarding changes. These interviews led the 3rd Conversation team to design “Ignite” experiences, where clinicians sit down one on one with health administrators and a facilitator to share their experiences in the system, build relationships, and work toward more integrated decision making.
These experiences are meant to be a starting point and to help organizations use a strengths-based approach to change and catalyze groups to focus on systems-level change. For example, there’s often a lot of anxiety when starting DEI work. So, starting with a 3rd Conversation experience where the group sees each other as human beings could ensure a more collaborative process.
While these are huge issues, learning that patients, clinicians, and administrators often want many of the same things, and creating understanding and empathy for how each of them experiences the system is a less contentious way to move forward and can help diffuse some of the preconceived notions and build relationships.
Learn more about Dr. Poorman’s work: https://www.drpoorman.org
Learn more about 3rd Conversation: https://www.3rdconversation.org
