M. Bridget Duffy, MD

The impact of clinician stress on the health care system is significant. It can adversely affect the patient experience, compromise patient safety, hinder the delivery of care in a manner that is inconsistent with producing quality outcomes, and increase the overall cost of care.

CLINICIAN STRESS IS PREVALENT

Models of health care that restore human interaction are desperately needed. Clinicians today are overwhelmed by performance assessments that are based on length of stay, use of evidence-based medication regimens, and morbidity and mortality outcomes. Yet clinicians have few opportunities to establish more than cursory relationships with their patients—relationships that would permit better understanding of patients’ emotional well-being and that would optimize the overall healing experience.

Shanafelt et al¹ surveyed 7,905 surgeons and found that clinician stress is pervasive: 64% indicated that their work schedule left inadequate time for their personal or family life, 40% reported burnout, and 30% screened positive for symptoms of depression. Another survey of 763 practicing physicians in California found that 53% reported moderate to severe levels of stress.² Nonphysician clinicians have significant levels of stress as well, with one survey of nurses finding that, of those who quit the profession, 26% cited stress as the cause.³

THE EFFECT OF CLINICIAN STRESSON QUALITY OF CARE

In the Shanafelt et al study, high levels of emotional exhaustion correlated positively with major medical errors over the previous 3 months.¹ Nearly 9% of the surgeons surveyed reported making a stress-related major medical mistake in the past 3 months; among those surgeons with high levels of emotional exhaustion, that figure was nearly 15%. This study also found that every 1-point increase in the emotional exhaustion scale (range, 0 to 54) was associated with a 5% increase in the likelihood of reporting a medical error.¹

In a study of internal medicine residents, fatigue and distress were associated with medical errors, which were reported by 39% of respondents.⁴

STRESS AND COMMUNICATION

Stress can damage the physician-nurse relationship, with a significant impact not only on clinicians, but also on delivery of care. The associated breakdowns in communication can negatively affect several areas, including critical care transitions and timely delivery of care. Stress also affects morale, job satisfaction, and job retention.⁵

In an examination of sentinel events in US health care, the Agency for Healthcare Research and Quality determined that a communication breakdown was the most common root cause of sentinel events in wrong-site surgery, delays in treatment, and medication errors, and the second most common cause (behind orientation/training) of adverse postoperative events.⁶ When root causes of all clinical categories of sentinel events were tallied, communication was found to be the most frequent contributor (training, patient assessment, and staffing were next) (Figure).⁶ The quality of the communication among physicians and nurses is a major influence on overall patient satisfaction and a patient’s willingness to recommend the hospital to others.

ADDRESSING THE IMPACT OF CLINICIAN STRESS

The traditional response to complaints registered by patients has been behavioral coaching, disruptive-behavior programs, and the punitive use of satisfaction metrics, which are incorporated into the physician’s annual evaluation. These approaches do little to address the cause of the stress and can inculcate cynicism instead.

A more useful approach is to define and strive for an optimal working environment for clinicians, thereby promoting an enhanced patient experience. This approach attempts to restore balance to both the business and art of medicine and may incorporate biofeedback and other healing services to clinicians as tools to minimize and manage stress.

The business of medicine may be restored by enhancing the culture and climate of the hospital, improving communication and collaboration, reducing administrative tasks, restoring authority and autonomy, and eliminating punitive practices. The art of medicine may be restored by valuing the sacred relationship between clinician and patient, learning to listen more carefully to the patient, creating better healing environments, providing emotional support, and supporting caregivers.

The impact of clinician stress on the health care system is significant. It can adversely affect the patient experience, compromise patient safety, hinder the delivery of care in a manner that is inconsistent with producing quality outcomes, and increase the overall cost of care.

CLINICIAN STRESS IS PREVALENT

Models of health care that restore human interaction are desperately needed. Clinicians today are overwhelmed by performance assessments that are based on length of stay, use of evidence-based medication regimens, and morbidity and mortality outcomes. Yet clinicians have few opportunities to establish more than cursory relationships with their patients—relationships that would permit better understanding of patients’ emotional well-being and that would optimize the overall healing experience.

Shanafelt et al¹ surveyed 7,905 surgeons and found that clinician stress is pervasive: 64% indicated that their work schedule left inadequate time for their personal or family life, 40% reported burnout, and 30% screened positive for symptoms of depression. Another survey of 763 practicing physicians in California found that 53% reported moderate to severe levels of stress.² Nonphysician clinicians have significant levels of stress as well, with one survey of nurses finding that, of those who quit the profession, 26% cited stress as the cause.³

THE EFFECT OF CLINICIAN STRESSON QUALITY OF CARE

In the Shanafelt et al study, high levels of emotional exhaustion correlated positively with major medical errors over the previous 3 months.¹ Nearly 9% of the surgeons surveyed reported making a stress-related major medical mistake in the past 3 months; among those surgeons with high levels of emotional exhaustion, that figure was nearly 15%. This study also found that every 1-point increase in the emotional exhaustion scale (range, 0 to 54) was associated with a 5% increase in the likelihood of reporting a medical error.¹

In a study of internal medicine residents, fatigue and distress were associated with medical errors, which were reported by 39% of respondents.⁴

STRESS AND COMMUNICATION

Stress can damage the physician-nurse relationship, with a significant impact not only on clinicians, but also on delivery of care. The associated breakdowns in communication can negatively affect several areas, including critical care transitions and timely delivery of care. Stress also affects morale, job satisfaction, and job retention.⁵

In an examination of sentinel events in US health care, the Agency for Healthcare Research and Quality determined that a communication breakdown was the most common root cause of sentinel events in wrong-site surgery, delays in treatment, and medication errors, and the second most common cause (behind orientation/training) of adverse postoperative events.⁶ When root causes of all clinical categories of sentinel events were tallied, communication was found to be the most frequent contributor (training, patient assessment, and staffing were next) (Figure).⁶ The quality of the communication among physicians and nurses is a major influence on overall patient satisfaction and a patient’s willingness to recommend the hospital to others.

ADDRESSING THE IMPACT OF CLINICIAN STRESS

The traditional response to complaints registered by patients has been behavioral coaching, disruptive-behavior programs, and the punitive use of satisfaction metrics, which are incorporated into the physician’s annual evaluation. These approaches do little to address the cause of the stress and can inculcate cynicism instead.

A more useful approach is to define and strive for an optimal working environment for clinicians, thereby promoting an enhanced patient experience. This approach attempts to restore balance to both the business and art of medicine and may incorporate biofeedback and other healing services to clinicians as tools to minimize and manage stress.

The business of medicine may be restored by enhancing the culture and climate of the hospital, improving communication and collaboration, reducing administrative tasks, restoring authority and autonomy, and eliminating punitive practices. The art of medicine may be restored by valuing the sacred relationship between clinician and patient, learning to listen more carefully to the patient, creating better healing environments, providing emotional support, and supporting caregivers.

The impact of clinician stress on the health care system is significant. It can adversely affect the patient experience, compromise patient safety, hinder the delivery of care in a manner that is inconsistent with producing quality outcomes, and increase the overall cost of care.

CLINICIAN STRESS IS PREVALENT

Models of health care that restore human interaction are desperately needed. Clinicians today are overwhelmed by performance assessments that are based on length of stay, use of evidence-based medication regimens, and morbidity and mortality outcomes. Yet clinicians have few opportunities to establish more than cursory relationships with their patients—relationships that would permit better understanding of patients’ emotional well-being and that would optimize the overall healing experience.

Shanafelt et al¹ surveyed 7,905 surgeons and found that clinician stress is pervasive: 64% indicated that their work schedule left inadequate time for their personal or family life, 40% reported burnout, and 30% screened positive for symptoms of depression. Another survey of 763 practicing physicians in California found that 53% reported moderate to severe levels of stress.² Nonphysician clinicians have significant levels of stress as well, with one survey of nurses finding that, of those who quit the profession, 26% cited stress as the cause.³

THE EFFECT OF CLINICIAN STRESSON QUALITY OF CARE

In the Shanafelt et al study, high levels of emotional exhaustion correlated positively with major medical errors over the previous 3 months.¹ Nearly 9% of the surgeons surveyed reported making a stress-related major medical mistake in the past 3 months; among those surgeons with high levels of emotional exhaustion, that figure was nearly 15%. This study also found that every 1-point increase in the emotional exhaustion scale (range, 0 to 54) was associated with a 5% increase in the likelihood of reporting a medical error.¹

In a study of internal medicine residents, fatigue and distress were associated with medical errors, which were reported by 39% of respondents.⁴

STRESS AND COMMUNICATION

Stress can damage the physician-nurse relationship, with a significant impact not only on clinicians, but also on delivery of care. The associated breakdowns in communication can negatively affect several areas, including critical care transitions and timely delivery of care. Stress also affects morale, job satisfaction, and job retention.⁵

In an examination of sentinel events in US health care, the Agency for Healthcare Research and Quality determined that a communication breakdown was the most common root cause of sentinel events in wrong-site surgery, delays in treatment, and medication errors, and the second most common cause (behind orientation/training) of adverse postoperative events.⁶ When root causes of all clinical categories of sentinel events were tallied, communication was found to be the most frequent contributor (training, patient assessment, and staffing were next) (Figure).⁶ The quality of the communication among physicians and nurses is a major influence on overall patient satisfaction and a patient’s willingness to recommend the hospital to others.

ADDRESSING THE IMPACT OF CLINICIAN STRESS

The traditional response to complaints registered by patients has been behavioral coaching, disruptive-behavior programs, and the punitive use of satisfaction metrics, which are incorporated into the physician’s annual evaluation. These approaches do little to address the cause of the stress and can inculcate cynicism instead.

A more useful approach is to define and strive for an optimal working environment for clinicians, thereby promoting an enhanced patient experience. This approach attempts to restore balance to both the business and art of medicine and may incorporate biofeedback and other healing services to clinicians as tools to minimize and manage stress.

The business of medicine may be restored by enhancing the culture and climate of the hospital, improving communication and collaboration, reducing administrative tasks, restoring authority and autonomy, and eliminating punitive practices. The art of medicine may be restored by valuing the sacred relationship between clinician and patient, learning to listen more carefully to the patient, creating better healing environments, providing emotional support, and supporting caregivers.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.