Heather Forkey, MD, on Burnout and Resilience
In this podcast, Heather Forkey, MD, discusses the mechanisms of burnout and how to use this understanding to restore resilience.
Forkey H, Griffin JL. Biology of burnout and remedies to restore resilience. Talk presented at: American Academy of Pediatrics 2021 conference; October 8-11, 2021. Virtual. https://www.eventscribe.net/2021/AAPexperience/login.asp?intended=https%3A%2F%2Fwww%2Eeventscribe%2Enet%2F2021%2FAAPexperience%2Fajaxcalls%2FPresentationInfo%2Easp%3Fefp%3DSlZYT1RRUloxNTA5Ng%26PresentationID%3D910095%26rnd%3D0%2E7144864
Heather Forkey, MD, is a pediatrician at UMass Memorial Health in Worcester, Massachusetts.
Stephanie Holland: Hello everyone and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your host, Stephanie Holland, alongside our moderator, Leigh Precopio, with Consultant360.
In the wake of the COVID‑19 pandemic, burnout among healthcare providers and patients is a source of concern for many. The first step to preventing and managing burnout is to have a robust understanding of how and why burnout occurs. Therefore, to restore resilience, one must begin with the biology of burnout.
This was a topic of a session recently presented at the American Academy of Pediatrics 2021 Conference. Session presenter, Heather Forkey, MD, is here with us today to answer our questions on burnout and resilience. Dr Forkey is a pediatrician at UMass Memorial Health in Worcester, Massachusetts.
Thank you for taking the time to answer our questions today, Dr Forkey. To begin, could you give us a brief overview of your session?
Heather Forkey: Sure, so the topic is officially about the biology of burnout and remedies to restore resilience. The discussion is intended to think about can we shift this conversation that when we talk about burnout, and 1 issue is that we are talking about maybe a couple of things at the same time. Not just burnout, which has a very particular definition as being overwhelming exhausted, cynical, and ineffective. There are probably some other symptoms that we can have go along with that in terms of exhaustion and feeling forgetful, frequently ill, and depressed. But in this conversation, we are often overlapping with probably some secondary traumatic stress, which is associated with but not exactly the same as burnout. That's the emotional distress from hearing about the first‑hand experiences of another.
There's some other terms that also get mixed up there, vicarious traumatization, which may be another term for secondary trauma. Moral distress, which is maybe a component of this. People come to medicine with their own experiences and exposures throughout their lifetime.
The first piece of the discussion is let's separate out what these different things are, and how we think about it. The second part of the discussion is around the idea that the suggestions related to burnout and secondary trauma have traditionally focused on doing self‑care.
As I talk about it, people say, "Find somewhere life balance, do yoga, and eat kale, and that's the way you should go.” More recently, people have begun to say, "OK, are there organizational factors that can play in?” Those organizational factors have started to be looked at. There's been impacts related to use of electronic medical records and redundancies trying to have people work to their license and be efficient in teams. All of that comes together in terms of thinking about - we're in medicine, and yet we never talk about these in terms of what physiologically, what is happening to people in these situations.
My day job is that I work with kids who are in foster care, and who had suffered from abuse and neglect. I think about trauma and the stress response. That's where we might want to start to think about what's going on for people because we humans have a range of stress responses. There is freeze and fight or flight, which most people have heard of. But we as humans are not that efficient with those. If we freeze and there's a predator, we're so big that we might get eaten. If we try to run or fight, we're not that good at it because we don't claws and we can't hide underwater.
The stress response that humans use most effectively is called the affiliate response, which is people look left and right and they say, "Are there humans here who can help me deal with this threat?" If there are people who can help you, your stress drops. You manage the threat. If you look left and right and there are not people who can help you, your stress rises. Now, you have to deal with all the people who won't help you, or who are coming at you, and you have to deal with the original threat. You get this upregulation and turning on of fight or flight that never gets turned off.
Anyway, that can be very informative as we talk about what's going on in terms of burnout, secondary trauma, or however you want to name what's going on. Ultimately, medicine is about dealing with threat all day every day. In days gone by, we worked with colleagues in a much more collegial way.
But modern medicine has isolated us. COVID‑19 has severely isolated us in that we see this rising. The ability to use that affiliated response goes away. We're left only with fight or flight. When we think about these symptoms, they are over our dysregulation of the stress response.
Leigh Precopio: That was wonderful. What are some best practices for preventing and managing burnout?
Heather Forkey: If you begin to think about if this is related to this dysregulation of the stress response, and this inability to use the most effective affiliate response, how do we turn that back on? How do we get back to using the affiliate response? Which is to reach out to other people and say, "Hey, can you help me deal with this?"
That comes from some individual practices. There are some things that we can do ourselves. It also relies on having leadership and organizations that focus on supporting those interrelationships among team members and promoting caring about each other, cultivating teamwork. Not just for efficiency, but so that we support each in the stress of this work. Then inspiring people to do their best work is also a form of tend and befriend.
The affiliate response is also called tend and befriend. What a great term because it says, "We're going to reach out and tend to each other and be there for each other so that we can manage these stressors in a much healthier way.” And so moving back toward those pieces as we can and away from things that are so isolating may be a way forward.
Leigh Precopio: Great. How can health care providers restore resilience either in the face of the COVID‑19 pandemic or in general?
Heather Forkey: There are some things that people can do individually in thinking about the stress response. One of it is recognizing that stress responses are normal. I think there’s some pathologizing of this that make people feel like I'm the only one and if this is not a normal reaction. Knowing that you're having a normal reaction to stressful circumstances, or even abnormally stressful circumstances during COVID is somewhat comforting. I'm not having something abnormal happened. I'm having a normal response to an abnormal situation.
Recognizing the physical cues of that stress response. The knot in your stomach. Your heart racing. Thinking about when you have handled stress in the past, and know that you have managed stressful things, and you can do it.
If we can focus on what you want to accomplish, and your intention, and in reaching out to others in those moments instead of pulling in and away from people but staying connected even if it's tough to do that more purposefully.
The second issue is to think about the role of, as I mentioned, leaders. There are some interesting literature that’s come out more recently on how leaders can promote wellness. What it boils down to is doing these things. Thinking about inclusion, keeping people informed, humble inquiry, not bringing a lot of ego to the table, but saying, "Hey, we're all in this together. How can we manage this together?"
Thinking about the skills of the individuals who are part of teams and capitalizing on those skills, so that the gaps are filled in. If you are skilled in one area, and my partner is skilled in another, that we're not constantly trying to work alone in the areas that we're not as good at but working together. That empowers not just the individual but the whole team.
There's also a recognition that people in medicine, particular in pediatrics, want to be compensated, but we're not all about the extrinsic rewards but much more about intrinsic motivators and focusing on those. That, again, promotes this affiliate response, and this ability to work with each other to decrease our stress and to come together around the challenges.
Leigh Precopio: My next question is, in your opinion, what needs to happen in order to reduce the burnout rate either to pre COVID‑19 levels or in general?
Heather Forkey: I think here's where I have looked at, we see this burnout rate rising, rising, rising. What's happening in parallel to the rise of burnout? What you see is a rise in people having to focus on doing the work all by themselves. Take the example of where I work.
We used to see patients and focus on our patients. Now I have an electronic medical record. I can't even look at the patient because I'm in an effort to not spend all day every day doing notes. I'm trying to get some of that accomplished. I'm not creating that same affiliate support for my patient. To them, it may not feel like I'm physically present. That diminishes their ability to feel safe and secure in the setting with me. They're reaching out to me seeking affiliate support. If they can't get it in that interaction, they may have more of a fight or flight reaction. We make those interactions more negative.
Now, I used to go out of the room and sit in a group setting with other providers and write notes and bounce questions off of them. We don't do that because we're all working, again, on this electronic medical record alone. We go back to our own offices and sit alone. We used to have conferences where we all got together. Now, we go, and we do anything conference‑wise, we do it electronically, again, in our own offices. We may be even doing telehealth all by ourselves in our homes and trying to get things done electronically.
The other thing is that in order for us to feel safe, there is a process called neuroception whereby we draw in information but we're not conscious that we're looking for safety. It's happening in our lower brain. How that happens is by perceiving auditory cues like tone of voice. A lot of it happens through looking at facial cues, and trying to see is this safe. Is this person going to help me? Can I draw them in in an affiliate way? Masked and on an electronic format, those same cues are much harder for me to perceive.
I have this underlying...It's an uncomfortableness. Our bodies are not able to perceive safety as easily. Many people recognize that they're more fatigued at the end of the day of zooming, or of doing telehealth than they would be with interacting with humans, and, in part, that's related.
What needs to happen in order to reduce burnout, or at least to pre‑COVID levels, is we need to be with other humans again. As we can get back to looking at people in the face and not through a mask, as we can get to having human interaction, as we can get back to conferences with other humans and not with our computers. That's part of what supports that affiliate response.
Also, thinking intentionally as an organization about are we doing things in the name of efficiency that ultimately, because they increase provider sense of a lack of safety, patient's lack of sense of safety, does it wind up being less sufficient in the long run?
Should we be thinking about ways where we can put people into physical connections and group work in a more intentional way with leadership who is aware that this is not just a nice side effect, that this is a primary goal of leading teams.
Leigh Precopio: My final question is what are the key takeaways from your session?
Heather Forkey: For people to consider some practical ways to promote that affiliate response in themselves and in others. What happens sometimes is that as we become stressed, we pull into ourselves. That's going to spin and cause you to have more fight or flight reactions and less affiliate responses.
Thinking intentionally, are their opportunities for you to reach out to others to build that sense of community in team in your setting? Can we begin to look at leadership in our settings? We tend to promote people who are good at research, or good at things that are not necessarily people skill. Can we begin to train people around supporting teams, supporting this development of individuals and thinking about others in this team format, and celebrate and reward leaders for doing that well?
Then, also thinking about what else in your life, outside of work, will help you promote affiliate response. It's not just yoga and kale. It is those relationships with others that allow you to decrease your stress response in a very practical way.
Sometimes we forget about the fact that we are being impacted, not just at work, but as COVID‑19 has kept us from people we love, our friends, our ability to affiliate outside of work. Do we need to be more intentional about re‑establishing those connections and getting back to some of those things that may have fallen off of our plate into ourselves during COVID‑19?
Stephanie Holland: Great. Thank you so much for joining us today, Dr Forkey. And for our listeners, catch up with all of our episodes at consultant360.com/podcast. Stay tuned for more.