Enhanced, Strategic Approaches Using the Processes of Judgment Index USA
The Facts of the Matter
In major writing and research projects from sources such as Mayo Clinic, The Journal of the American Medical Association, Atlantic Monthly, and the Huffington Post, it has become abundantly clear the anecdotal experiences relating to physician burnout are being confirmed in exceptional research. Healthcare organizations across the United States are rushing to find ways to respond to the growing magnitude of the problem, fully realizing the implications for physician partners, organizational reputation, and—most significantly—patient care.
Here are the facts:
- One-third of extensively surveyed physicians reported experiencing what they personally identify as burnout.
- Physicians are 15 times more likely to experience burnout than any other professional career.
- 45% of primary care physicians surveyed report that they would quit their jobs and change professions if they could afford to do so.
- There is currently a 20% higher divorce rate among physicians than other professionals.
- 300-400 physician suicides a year.
- Medical students report treated depression at rates 30% higher than a decade ago.
- There are 6.2 times more medical errors being reported by burnout physicians.
- A 2011 Mayo study reported 50% of physicians reporting at least one major symptom of burnout.
- The number of physicians reporting “suicidal ideation” (thinking about taking their own lives) rose from 4.0% to 7.2% in past five years.
- 20% of physicians reported worst work-life balance issues in past five year.
Therefore, we are well past either wondering or assuming that there are physician burnout issues. The magnitude of the problem is obvious. To leave this particular situation unaddressed would create massive “exposure” issues for healthcare in the United States. The question is: how can the problem be approached strategically?
As a minor disclaimer, there are individuals and organizations that do not like to use the word burnout. There is also a certain mentality that suggests that an individual using the term is advancing a form of “weakness” that a truly strong person should never use and be able to “suck it up” and overcome. If anything, this mentality probably adds to the problem, and creates unnecessary, additional pressure on those struggling. However, if there is ever a need to avoid these kinds of negative associations, we are completely willing to use the terminology “renewal” or “Physician Renewal Program.”
Developing Specific Programs
The present response to these critical issues has been quite simple—we need a “program” where physicians will be encouraged to become involved in the “program,” and that will help make the problem go away, give resiliency for dealing with the problem, or at least give us the chance to say that we have tried to approach the problem. Such programs are certainly well intended and should be pursued. To date, participation in the programs that have been offered has been negligible, and often there has been no constructive way to create awareness proactively among physicians of the degree to which they may need the program. It is also very important that anyone becoming involved in these kinds of programs have great experience and credibility relating to healthcare environments.
The “Judgment Index” is an assessment instrument that is designed to give additional—and unique—insight into human beings relating to both the work-side and the self-side of their lives, and the alignment and connection between these two dynamics. The instrument can be used with other assessment tools and processes in order to give a fuller and more complete set of insights. The more that we can know about human beings, the better we will be positioned to give additional items for both prevention and remediation.
The “Judgment Index” is not a cognitive, rational intelligence—IQ type—instrument. This fact is very important, as reality such as physician burnout have not proven to be enhanced by high rational intelligence. In fact, very highly rational individuals suffer the most ominous problems because they cannot “reason” their way to solutions. The “Judgment Index” is also neither a psychological nor—most importantly—a personality tool. In regard to physician burnout, psychological tools can be of benefit if they are designated; however, it should not be assumed that they should be used. “Personality” is simply not a fully adequate mechanism for dealing with a complex issue such as physician burnout and is a lagging indicator of behavior not a leading indicator.
Uniquely, the “Judgment Index” looks at a person’s judgment, along with trained skill sets and experience, the most significant functional asset possessed by a physician. Patients, peers, and organizations depend on physician judgment, and this asset is most profoundly made vulnerable by the variety of factors that create burnout.
- We begin by administering our assessment instrument, assimilating information, and creating reports for physicians and physician groups. In most instances, we do our work for those who are coming into physician burnout programs. A much better strategy would be to get as many physicians within a healthcare setting to take the assessment. In this way, we can absolutely know who needs the burnout work the most, and we can report on the intensity of the problem as it is being revealed in real-time settings. We hope that physicians will be made aware of the degree of their problem and then will participate in the programs designed. Some will choose not to for a variety of reasons. For these individuals, there is still valuable information that can be provided that will enhance awareness, and perhaps cause engagement with some of our (or other) learning management system materials designed to help in areas of weakness.
- For those involved in specific programming, both group and individual feedback is made based on assessment interpretations. The key aspect here is awareness, and we have found awareness to be a profound catalyst to change and improvement. We regularly provided program presentations and follow-up counseling.
- We are fully capable to engage with other assessment instruments and processes in addition to our specific areas of concern noted below if so desired. Our processes are not “canned,” and we customize based on a full understanding of individual organizational needs.
- We can also, unlike most other assessment instruments, provide pre- and post-testing which will give a clear indication of progress made and—perhaps—progress still needed. Such incremental information can continue beyond the formal program at intervals desired by the participants.
The Maslach Burnout Inventory
In our experience, the MBI is the best Likert-style instrument that has been created to address these issues of burnout. By “Likert-style,” we mean an instrument that asks various questions of physicians to determine frequency of symptoms or indicators that have proven to align with burnout manifestations. The tool’s usefulness has been advanced with credibility at Mayo Clinic and other critical institutions. The information that is gained is very helpful.
We make full use of MBI data when an already existing program has acquired it. We build exacting correlations between our interpretative scoring patterns and this data to give synergistic information based on both tools. When the MBI data is not present, we are able to do the surveying and assessment ourselves without outside or additional consultant help. We can provide all individual and group feedback based on the MBI, and we strongly suggest that we be allowed to incorporate this information as part of our data feedback and interpretation.
Please note carefully that the “Judgment Index” is not a Likert-style questionnaire, assessment instrument. We come from a completely rational and deductive base while the Likert-style assessment is more inductive. Induction has not been traditionally seen as providing the most dependable data, and questionnaire types of devices have been prone to idealistic “halo effect” in their answering process. This being said, we are still strong supporters of the MBI as compared to other Likert-style assessments. We simply provide measurable and quantifiable scoring patterns which give real numbers for participants to work with in their assessment and development. Correlating anecdotal measures with quantifiable measures becomes a stellar means to gain greater, more functional insight. Our approach with the MBI and the “Judgment Index” would be decidedly “both-and” and not “either-or.” Again, we can provide the MBI services as part of our contribution to a physician burnout program.
While there are a wide variety of approximately 80 different measures that can be discerned from the “Judgment Index” that provides a comprehensive view of human judgment and decision-making capacity (both available or impaired), we have tended to focus on the following areas as they relate to physician burnout:
- Stress that is present (in four categories), the intensities of these stressors, and the coping ability that a person has for dealing with these stressors.
- The importance to an individual of control and—correspondingly—the impact of the lack or loss of control.
- The capacity that a person has to set limits so that there are abilities to integrate rest, recreation, recharging.
- The intensity of a person’s self-expectation and self-criticism.
- The capacity of a person to distinguish between what is really “important” and what is merely “urgent.”
- The strength (or absence thereof) of work-life balance.
- The capacity to recognize and act upon implications, consequences, and “bigger picture” realities that transcend present-moment realities.
- The presence of strong self-esteem and its relationship to confidence.
- The presence of a sense of the value, meaning, and purposefulness of work.
- The capacity to deal with difficult situations and difficult people.
In addition to these specifically related burnout indicators, we also will look at indicators that have high implication for safety and risk management. We will be able to create awareness around scores show strong judgment (or lack thereof) that contributes to greater safety and risk management. These indicators include:
- Attention to the ability to remain focused in the midst of distractions.
- Attention to the ability to hold value for following directions, protocols, best-practice solutions.
- Attention to noticing, that which is subtle and nuanced in a situation.
- Attention to cleanliness of larger environment.
In addition, we will also use one of our very most insightful reporting instruments, “The Engagement Report,” to analyze the degree to which a person is fully engaged in the work that is being done. We closely look at four primary core indicators of engagements and three sub-categories within each major indicator. The report is often used as the core of its own separate presentation in a program. It is able to “thin slice” and demonstrate precisely what issues are creating a lack of positive engagement.
The Importance of Rest
Almost without exception, our work in this particular area has seen a strong correlation between burnout and rest. Most physicians, when they are working with a wide variety of maladies impacting patients, will give strong emphasis to the reality of rest. Yet, most physicians do not apply this same formula of inquiry to their own lives. Most people, even physicians, do not have concrete, measurable insight into their own unique dynamics of rest. Therefore, we suggest that accompanying the other activities suggested in our strategies that an individual add a formal sleep study in order to determine these unique elements of rest. What is enough sleep? What kind of sleep is actually being achieved? Are there obstacles to sleep and good rest? All of these kinds of questions are essential.
At a recent presentation, I asked a group of 100+ physicians how many had done some sort of cardiovascular testing in the past year. Almost 100% raised their hands to acknowledge a positive response. I asked how many had done gastrointestinal testing, and with some degree of laughter knowing what is involved with this testing, about 75% raised their hands. When I inquired about sleep studies—with lack of proper rest a common component of both cardiovascular and gastrointestinal problems—two individuals in the large group indicated a positive response.
How People Change
Clearly, if there is physician burnout, there is a desire to change to a better situation. Therefore understanding how people change becomes important to the way in which we carry out our work. In our studies, the most compelling way that people change is because of pain. This is, of course, why many people would find their way into a burnout program initially due to physical or mental anguish. Of course, it would be hoped that such pain could be proactively approached, but often it simply is not.
The second, most significant way that people change is awareness. Awareness can be a powerful catalyst as attention is captured and motivation increased. The “Judgment Index” does a profoundly significant job of capturing awareness, and demonstrating how it can best be channeled to produce sustainable change. The tool is like a scale on which a person is weighed. The scale, particularly because it has numbers, captures awareness and also provides a benchmark that can be used to assess change—hopefully productive—in the future.
Change can be greatly assisted with conscious and intentional mentoring. Most mentoring is haphazard and neither very conscious nor intentional. By using quantifiable scores from the “Judgment Index,” mentoring can be carefully calculated so that individuals who are strong in one particular area of need can be matched precisely with individuals of weaker scoring patterns. This process has been proven to create highly predictable improvement. In addition, if used properly, can establish informal bonds of communication and support that are important in any kind of improvement process.
Finally, it is true that change can be advanced in positive directions by instructional information. Having been a college and university professor for twenty-five years, I certainly have an appreciation for instruction. However, instruction is not an immediate or guaranteed remedy, and should follow other strategies as reinforcement. Our Learning Management System (LMS) has programming specifically designed to help in areas usually impacted by burnout. Incorporating these web-based, independent study elements into an overall physician burnout program has proven to be of substantial benefit.
Taken together, and used in strategic process can create enough of a focused exposure that long-range reinforcement of concepts and activities can allow for a greater assurance of success.
We are prepared to create and carry out a fully developed physician burnout program for an organization on a single or ongoing basis. We can provide a “turn key” activity, or we can contribute elements to an overall program. We are able to do one presentation or several presentations relating to an overall program. At a minimum, we would like to do the following pieces:
- Assessment and introductory interpretation presentation on findings, resulting in a developmental plan for improvement.
- In depth presentation correlating “Judgment Index” findings and Maslach findings.
- In depth presentation on “Engagement” and other key indicators, resulting in developmental enhancements.
- Post-testing to assess improvements.
Also, please keep in mind that we see it as ideal to engage participants in face-to-face encounters and conversations over prescribed periods of time. If/when this ideal cannot be achieved in a program-like setting; individual assessment and feedback can be much better than nothing.
Financial discussions obviously involve a number of variables depending on what parts of options are selected for incorporation. We are committed to the idea of providing quality programming that has high impact as costs that are not prohibitive. It would be very difficult to calculate precisely the return on investment relating to reducing physician burnout and its implications for peer interaction and patient care.