Dr. Steven Hippler
Contrary to what most people would have believed, we found that there was no relationship between work hours, call burden, and burnout. And actually, we found the higher engagement in those people who were working the hardest. So the narrative is that it’s all about the amount of work, it’s about the call burden, it’s about the EMR. Yet, those with the skills to be able to manage all that with the least amount of frustration, we believe, are those people who will have a lower risk of burnout and a greater sense of well-being.
Dan Shellenbarger
That was Dr. Steven Hippler talking about some of the surprising trends that he and his colleague Larry Weinzimmer have found while researching clinician burnout. Hippler is the former Chief Clinical Officer at OSF HealthCare based in Peoria, Illinois, and Weinzimmer is a research professor at Bradley University. The two have embarked on a research agenda to find ways of combating both burnout and turnover in the healthcare workforce. One of their chief discoveries is that fortitude plays a significant role in determining whether a person can manage their well-being and overcome the many obstacles that often lead to burnout.
In this podcast with Oliver Wyman’s Dan Shellenbarger, Hippler and Weinzimmer discuss their research and what it takes to nurture fortitude within the healthcare workforce and what that means for lowering burnout and reducing turnover.
The Oliver Wyman Health Podcast is brought to you by the global management consulting firm Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health.oliverwyman.com. And now let’s pick things up with Hippler explaining how their research agenda got started.
Steven
Larry and I have been talking about this issue for four or five years, and it really started with the belief that the prevailing explanation for what causes burnout among physicians was incomplete. If 50% of physicians are burned out, there’s 50% of physicians in the exact same work environment who don’t get burned out. And as we’ve seen across the last 10 years or so, the incidence of physician burnout has really not gone down and the solutions have not been wholly successful. So, we started our research looking for why is it that certain people burn out in environments and certain do not.
Dr. Larry Weinzimmer
What we also found anecdotally is if you think about those that burn out in the same work environment, oftentimes they’re just trying to meet that minimal level of accepted productivity, and those that are really engaged, working hard, and passionate about their jobs might be working more hours, yet they’re not burned out.
Dan
What are the hallmarks of physicians who are able to be more resilient and have greater fortitude in their clinical practice? What are the things that you guys have uncovered that help us see some of those bright spots?
Steven
Well, Dan, I’ll take that question. We started by looking at resilience because in healthcare we talk a lot about resilience or the ability to bounce back after you’ve been knocked down. We started this conversation with how do we engage people, so they don’t get knocked down in the first place? And that led us to the literature on burnout outside of healthcare. There’s a large body of literature on grit in the academic literature. So those who have a higher degree of grit are much more likely to succeed at school, medical school, residency, nursing school. That passion and perseverance and grit is talked a lot about in academia, and we don’t talk a lot about it in medicine.
There’s another attribute of self-efficacy or skills that gets published a lot in the teaching literature. Actually, teachers who can’t control their classroom, who don’t have that skill, are much more likely to burn out and leave the profession. That was before COVID. After COVID, those teachers who don’t know how to do remote learning have a higher risk of burnout and leaving. And that’s just not something we talk a lot about in medicine. Although there is a study from the United Kingdom that showed that physicians in the bottom half of their class have a higher risk of burnout. We also looked at resilience and hope and optimism. And so we looked at all these interpersonal attributes that don’t always get talked about in medicine, and that formed the basis of our understanding of fortitude.
Larry
As Steve just mentioned, seven different sub-dimensions. Interestingly, in the literature, these seven sub-dimensions all spend considerable effort arguing why they’re different from the other measures. Again, we took a different approach and rather than arguing that they’re all different, we wanted to see if they were similar. And across these seven dimensions, we found items in the scales that were literally identical for beta. And so we came up with an original list of similar items across these seven scales, it was 96 items.
We narrowed it down to about 35 items based on repetition. And then we had 13 focus groups of physicians and [advanced practice providers] APPs that helped us narrow this down ultimately to a 12-item scale. And we’ve tested this scale on fortitude across three different empirical samples. We wanted this to be an evidence-based approach. Our scale for fortitude is able to predict burnout four times better than the next best scale, or stated differently, resilience can explain about 10% of variance in burnout. Our fortitude measure explains over 40% of variance and burnout. So we’re really excited about the effectiveness and efficacy of the scale that we developed in our attempt to understand burnout better.
Dan
Yeah, it’s really interesting, and I think what will be fascinating is to see how we can apply this scale and this notion of fortitude going forward. So how are you guys thinking we apply fortitude as we go forward?
Steven
We’ve applied fortitude as a way to educate physicians. And Dan, let me mention for your listeners that we believe that burnout is a human phenomenon. We’ve studied physicians, but this applies widely and broadly across everybody. We start seeing now in the literature things about burnout in teachers, burnout in parents, couples, students. So we believe burnout is a human phenomenon, and that fortitude is a human interpersonal attribute that can be built in every person to improve their well-being.
We’ve applied it by having seminars to teach and train and educate individuals on the whole concept of fortitude. And one of the things we’ve learned in doing that, Dan, is too often we’re seeing people passively accepting the fact that they’re burned out because of the work environment and they’re looking for somebody else to fix it for them. When we did some of our initial validation scales, we talked to some physician leaders who were leaders of their physician group, and they were almost in tears because they know it’s a problem. They know they need to do something, but everybody’s looking at them to fix it. So when we give our seminars, we make it very clear to people that the work environment’s really important, but there are things that you as an individual can do to improve your own fortitude and to improve your well-being.
We’ve been giving these seminars on fortitude and in our first one where we did it with physicians and APPs and leaders in medical groups, we compared fortitude and burnout at baseline in a group and also studied a control group of people in a similar work environment. Four months later in our intervention group, fortitude went up and emotional exhaustion went down and we didn’t change at all in the control group. So we are really excited about the fact that fortitude is a concept that can help empower people to take control of their well-being. And through what we’ve offered them in seminars and facilitated group coaching, individuals now can come up with solutions to improve their fortitude and well-being in the workplace regardless of what the workplace is.
Larry
And oftentimes, when we presented our original research on scale development, we had the question, “So what? These findings are interesting. Fortitude is great at predicting burnout, but so what?” And we define fortitude as a malleable trait. What we mean by that is, it’s a perspective, it’s an attitude. It’s something that can change. And so as Steve mentioned, this facilitated group coaching that we do, or the seminars we do, have had a statistically significant impact on improving fortitude and reducing burnout. And so we’re really excited about the potential for that.
Steven
And Dan, one of the things that struck us through this journey is I think back to when I was a chief clinical officer over a large physician group, and I went and looked for programs and solutions to the burnout problem and found a lot of one-size-fits-all programs. What we learned through this journey, and as we do our facilitated group coaching, is that everybody’s burnout and frustration is caused from something very, very different. So as we lead them through this facilitated group coaching with fortitude as our underlying premise, what we see is people come up with very different and unique solutions to their own current frustrations
Dan
Is fortitude static or dynamic? There’s no shortage of interventions around trying to fix fortitude the same way. There’s no shortage of focus on how do we get greater productivity, improve quality, and outcomes. Right there, there’s no shortage of other pressures being placed on physicians. I’m curious, just again, back to this notion of it’s a dynamic environment, how do we think about introducing fortitude? While we’re also introducing so many other things into the clinical environment?
Steven
We view fortitude as an opportunity to focus on helping a person improve their well-being. As Larry mentioned, our research has shown that perceived organizational support only leads to improvement in burnout in people who have fortitude. So anecdotally, we all know of those individuals, perhaps, in the work environment who we’ve all tried to help, but nothing seems to help their well-being. Perhaps it’s time to focus on their level of fortitude and help them build fortitude, build the skills they need to do well in the environment as the next strategy to improving burnout. Because clearly, the one-size-fits-all approach will not work.
Larry
It’s not the organization, it’s the individual and the organization. It’s that interaction between the individual and the organization that can influence burnout. And statistically, we found that to be very true.
Steven
Contrary to what most people would have believed, we found that there was no relationship between work hours, call burden, and burnout. And we found the higher engagement in those people who were working the hardest. So the narrative is that it’s all about the amount of work, it’s about the call burden, it’s about the EMR. Yet, those with the skills to be able to manage all that with the least amount of frustration, we believe, are those people who will have a lower risk of burnout and a greater sense of wellbeing.
I think in medicine, we’ve been a little hesitant to say that there are skills that physicians and nurses… and, honestly, in the workplace, there are skills that we all need to work on. Nobody enters a complex, tough work environment with all the necessary and requisite skills to be successful. I think we need to acknowledge that there are people who just need to build skills and build fortitude to be successful regardless of whatever the work environment is.
Dan
So this is really interesting and feels like a breakthrough, right? It feels like something new for us to take and apply in the world, which is progress. Where do you guys go from here? What’s next on your agenda for research and pushing forward?
Larry
We’re launching another study looking at nurses and nurse fortitude, nurse burnout. We’re also launching a study taking a look at the role of fortitude in the relationship between AI assistance on EMRs and burnout. And we’re working with the healthcare organization with 17 hospitals. They’re rolling out an AI platform to help physicians and APPs manage EMRs. And we’re going to look at the role of fortitude as an intervention or, as a moderator, impacting the relationship between this organizational intervention, in this case, AI platform for EMR and burnout.
Steven
And Dan, if people are interested in more information, our studies, we post on our website, www.nexusinsights.com.
Dan
Larry, Steve, thanks. That’s awesome. Thank you.
Steven
Thank you.
Dan
The Oliver Wyman Health Podcast is brought to you by the global management consulting firm Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health.oliverwyman.com.
This transcript has been edited for clarity.
