Battling burnout in healthcare: the importance of a positive work culture

Sasha Shillcutt, MD

Cardiac anesthesiologist and founder of Brave Enough

Battling burnout in healthcare: the importance of a positive work culture

23 March 2020

Quick Takes

  • Burnout is a serious challenge in healthcare institutions that can have detrimental effects on patient care if not attended to

  • Healthcare leaders can help decrease burnout rates among staff by ensuring a culture of acceptance, understanding, and transparency

  • Surprisingly straight-forward and effective strategies can be put into place to help achieve a supportive culture, which ultimately leads to improved patient care

Sasha Shillcutt is a physician, gender equity researcher, speaker, author of “Between Grit and Grace” (released February 2020), and founder and CEO of Brave Enough. 

She sat down and talked to us about the importance of recognizing burnout in healthcare, building resilience, and what leaders can do to mitigate the crippling outcomes of burnout in their organizations. 

This is part two of our honest and inspiring interview. Be sure to also check out part one. 

Creating a culture of acceptance

Engaged workplace culture with gender equity

Well cultures are cultures that make all of their employees regardless of race or gender feel safe, equitable and valued.

Normalize failure

HT: You gave a TedTalk on resilience and this idea of normalizing failure within healthcare institutions. Could you elaborate on the importance of creating a culture where failure is a normal daily occurrence? 

Dr. Shillcutt: This is a great question. The reason I am so passionate about talking about failure is that in healthcare, specifically, we tend to only accept perfection in outcomes as the gold standard, in the everyday standard, and yet we are humans. We work in a very human-driven environment which is why people go into medicine. 

People are drawn to healthcare and they’re drawn to medicine. Whether you are the receptionist that’s working at the front desk or you are the scheduler, or you are the lab technician, or you are the physician, you are drawn to healthcare to help people and because you have human skills where you want to be part of that team. 

So, while we recognize what drives us in healthcare is very human work, we have a very perfectionistic expectation every day on teams that we’re not going to fail. We’re not going to miss the diagnosis. We’re not going to make a clerical error. We’re not going to fail to do a procedure correctly. We’re not going to forget to call a consultant. 

While we’re drawn to healthcare for human reasons – that are wonderful reasons – we have this expectation that there absolutely can be no margin of failure. When a failure happens, what we often do is that we have shame or we hide it or we have a lot of negative feelings and emotions associated with it because we really care about people, and yet we have no way to share it and be vulnerable – it’s not ok. 

There is this culture of this person messed up and we’re not going to talk about it. We’re going to disclose it to the family and to legal, but then we’re not going to talk about it, and that’s the end of the conversation. What happens is there is a lot of shame that can be carried by people in healthcare from mistakes that they made 20 years ago, 10 years ago, 30 years ago.

When I go to give a talk about failure in healthcare and how we need to talk about it and share our failures, at the end of every talk – it doesn’t matter where I am, what state, what city – there is a line of people with tears because they have carried shame for a previous failure. 

I know that if you read the literature, it says that when people feel part of a team and they feel valued and protected, they’re more likely to share their workplace failures or workplace obstacles. This is the key, because when we share, we find answers and we prevent other people from failing in the same situation. We need to create a culture where it’s ok to share failure, and yet every time I speak on this topic, there are people that have held this in for 20 years, 10 years, 15 years. They have never talked about it with anyone. 

What we’ve started to do in medicine that I think is so critical, is that we’ve started to debrief and really protect people and say, “You know what, let’s talk about this scenario, not from a legal or documentation standpoint but from the person(s) who were part of the failure. Let’s talk about what happened.”

It’s amazing to me how many people have created a story in their mind. Maybe the event happens and you don’t debrief for two weeks and in those two weeks, the person who feels responsible for the mistake has created a story. In that story, they typically blame themselves, and yet most of the time we know that when failure happens in medicine it is a system problem. It’s multiple little things that happened that lead to a bad outcome. 

The importance of having this discussion where there is no blame, no shame, but you actually talk about and teach about the failure, and you let the person open their eyes, you create a different story that allows everyone involved to learn from the failure and improve outcomes. The story they create is: I was part of a bad outcome where I may have played this role, but I learned this, and I didn’t recognize or see now this system problem and let’s fix it so that it doesn’t happen again. Maybe I had failure blindness where I couldn’t see what was going on around me. Now my eyes are open, also to the shame associated with it, and I’m not going to carry it forward to the next day or the next patient. It’s not going to lead to me as a healthcare provider having a bad or negative behavior like substance abuse or suffering from anxiety or taking it out on my family.

It is so important that people feel safe to discuss problems and failures and negative outcomes in healthcare. 

HT: From a leader’s perspective, what can be done to create a safe space and willingness to sit down and speak about failures objectively to try to fix the systems that are broken?

Dr. Shillcutt: That is a great question. For leaders it is really powerful when you share your own failures in front of people who are in your charge. There is a lot of discussion often about this around leadership tables because the common perception is that everyone wants to see our leaders as infallible, and we want to see people at the helm that we think are extremely qualified. 

However, we also know that when you share your own failures or previous challenges, you open the door for other people to share theirs. You promote a culture that allows people to share their mistakes or misgivings, which then opens the door for a safe culture, a well culture. I know there have been several institutions lately that have had a narrative medicine evening where they’ve invited leaders – physicians, executives, and people that are leading within the organization whether it’s nurses or pharmacists – to share personal stories of failure and resilience. 

It is so incredibly powerful. I can tell you that the times that I’ve failed on a minor scale, which to me at the time felt so major, I was able to quickly recover and bounce back when someone who I admired reached out to me and said, “You know what Sasha, I have failed in that way 10 years ago and I recovered and this is how.”

I looked at this person as an idol.  Or perhaps a leader that I strived to emulate. Suddenly they’re admitting their own failure or their own struggle or how they overcame a previous work obstacle, which is huge. So, I would say the best thing leaders can do is share their own failures with their teams and be brave enough to really be vulnerable with the people in their charge. 

Support gender equality

HT: Was that the motivation of starting the Brave Enough Community?

… women should be able to lead in spaces and should feel supported in spaces without having to give up their authenticity or without having to give up who they were.

Dr. Shillcutt: The reason I started the Brave Enough Community is that about 5 years ago, despite being considered a very successful woman in medicine, I found myself feeling extremely isolated and wanting to quit medicine. If you would have come to me and said, tomorrow you cannot be a cardiac anesthesiologist and still pay your bills and you could sell yoga pants, I would have said, sign me up! Which is really sad and scary because I invested a decade and 2/3 of my life to become a physician. It was a wakeup call for me.

I recognized how isolated I was, and so I started Brave Enough because I felt that women should be able to lead in spaces and should feel supported in spaces without having to give up their authenticity or without having to give up who they were. Part of the reason why I was burning out was because all of my mentors and the people that were leading me and that I looked up to didn’t look like me – they weren’t moms of 4. They were typically men and they were a decade older than me, so I was trying to emulate them because I wanted to succeed and I looked up to them so much but the problem with that is: I will never be a 55 year old white male. 

So, I had this huge identity crisis because how I was trying to be every day at work was not who I was as a person, and so that’s why I started Brave Enough. It started with 10 women that I invited to join me to encourage and support one another to be authentically women leaders in the workplace and it just started growing. 

Now there are 11,000 women and we have conferences and classes and retreats, and it’s really amazing the network and the support that is there, and the success and the leadership and the health and well-being that these women bring to their organizations when they feel that it’s ok to lead as a women. 

HT: Why are women often underrepresented at the highest level of leadership in healthcare in essentially every country in our world? How can we change this?

Dr. Shillcutt: I love this question. It’s a webinar in and of itself. There’s a great infographic that the World Health Organization put out and it looked at the pipeline of women and it has the pink woman in a dress and the little blue stickman in a suit, and when you get to the highest level, I use this infographic in my talks, the only thing that we have are the feet, it’s not even a whole body – it’s hysterical, you’ve probably seen it. 

It is a huge problem, and the reason for that is because the backlash that we have as women as we go through our career. Over a 30 year career, on the one hand you have leadership backlash and on the other hand you have social backlash. What happens is as we grow through our career, women can experience more and more backlash, because as we age, we’re more a threat to power. 

So, if you are a really strong woman, you may be seen as competent. Say you are an extrovert, say you have a strong personality, say you are aggressive and assertive in the workplace – all things that are seen as positive traits in a leader, unless you are a woman. So you start getting leadership backlash and you start toning it down. 

Let’s say you are on the other side of the spectrum, you’re a great team player, you’re a collaborator, you’re a team builder, you may have a more quieter, introverted personality. Maybe you don’t speak up as much but you have a lot of great ideas – all of these are great attributes of a leader if you’re a man, but if as a woman, you’re seen as too soft, so you start to pull in your ideas, your creativity, and not share them. 

Over the course of our 30 year career, the margin of how we can be as a successful woman is very narrow, and then we get labeled as the ‘Queen Bee’. We all know these as women. The woman that is at the top, but that walks in and keeps to herself and doesn’t really communicate with other women. She does her own thing and is separate from the men. Well, why do you think that is? It’s because she’s been driven by this social and leadership backlash to operate in this very narrow margin of leadership where she knows that she can be successful. 

And then as women, when we get to this point where we’re going to level up and go to the next level, we look at that and say, “Well, I don’t want to be like that. I don’t want to be like this ’Queen Bee’ woman, and I certainly don’t want the life of the men because I can’t have that life. I will never be that.” So, internally, we are at a conundrum. 

We may have the skills, the expertise, and all these things, but we are unable to push through the glass ceiling, so to speak, because we know that we will never have that job-fit, and the roles at the very top were not created for women, they were created for men. That’s why 87% of the people that are leading healthcare at the second managerial level or above are men. 

It’s not that women aren’t qualified or that they don’t make good leaders, it’s not that women don’t see themselves as leaders, it’s that they see the role and they say, ‘why would I want to do that if I’m going to get all this backlash,’ or they may have tried for a third level managerial position and are told that they’re not ready yet, but then see it go to someone who was maybe a less experienced male, and then think, ‘wait a minute, I have all these skills but I don’t fit the personality or I don’t fit the role? Why would I want to try for the next position?’

So, it’s very complex and that’s why when I hear people criticize women at the top, these Queen Bees, I think, ‘do you even know what it took her to get to that stage?’ I bet it’s very isolating and lonely. So, what can men do? – the second part of the question. 

Steps leaders can take to support women in leadership

How leaders can support women in healthcare leadership roles

This is critically important.  I started this statement of three words: More Than One. I get asked this question every time I give a talk, often by male leaders who really want to help, who really feel passionate and who have woken up to all the data and say, ‘wow, I look around and there are no women, how can I help more women?’ 

1. Involve more than one 

First of all, have more than one woman there. There is significant data to show in Fortune 500 companies that when there is more than one woman at the table, men are going to listen to women more and women are going to speak more. It’s because the women at the table, even if they don’t know each other, they feel that the culture supports women when there is more than one woman. Always make sure that there is more than one woman at the table where all decisions are being made. 

2. Be compassionate 

If you’ve asked a woman, and she says ‘no’, don’t stop there, ask, ‘why are you saying no? is it because we are making all of the meetings at times when you are going to be picking up your kids because you’re the mother in this family dynamic?’ That’s reality, only women can have babies. Let’s wake up, it’s 2020, and embrace that. So, why is she saying no? Is it because she’s going to be the only woman and she’s not going to feel welcome or heard, and we’re not creating a culture that welcomes women? Why is she saying no? Is it because she’s been told that she can’t do the job, or she’s not being welcomed in the culture?

3. Accommodate 

The third thing is to change the roles. We are so smart in healthcare. We come up with such amazing discoveries and new technologies every day, whether it’s our electronic medical record or mechanical heart, but often we struggle to think outside the box to change a role to fit maybe a woman who has a family or to fit someone maybe who has a personality that we don’t understand because this role has never gone to a woman, and so we really can’t comprehend it. 

Well cultures are cultures that make all of their employees regardless of race or gender feel safe, equitable and valued. There is a lot of data that shows that when you make your employees feel valued, when you pay them for what they’re worth, when you promote them equally and when you make them feel safe from harassment or bias, you create a well culture, and that leads to decrease burnout. 

HT: You expressed that women are always put in a position of finding a balance between being too much or not enough of something. Can you comment further?

Dr. Shillcutt: It’s like personality ping pong, and it is exhausting. The messages that we get as women are that you’re always too much of something. I’ve been told on one occasion that I’m too loud or I talked too much, and then I’ll go to a meeting and someone will say, “Oh, you didn’t talk much, you should’ve talked more.” These mixed, bias messages lead to personality whiplash. We have to stop that message that if you’re a woman, you’re always too much of something. 

Digitalization to alleviate burnout? 

HT: One advantage of digitalization in healthcare is to aid physicians by decreasing time spent on consuming or repetitive tasks. Do you feel in the near future that it will allow you to focus more on patients and relieve some of that burnout that is so pertinent today?  

Dr. Shillcutt: Great question. Oftentimes we create systems with the intention to make less, more efficient and safer work. At the end of healthcare is always patient safety and patient efficiency and how do we bring value to the healthcare system and how do we sustain it. 

It comes from a good place, but oftentimes what happens is that we don’t support people who are the end users of the systems – we don’t involve them in the conversation or the building stage of whatever system or technology that we are hoping to invent, innovate or improve healthcare delivery. 

For example, I’m an anesthesiologist. I work in an operating room where I have to transfuse blood, and part of patient safety is for me to check the blood that comes through the blood bank to make sure that that unit of blood will not cause a negative reaction in the patient that I’m transfusing, so we have a check system that we go through. 

We recently changed that check system and the process of the checking was really driven to improve patient safety, but what happened was it went from three clicks on a computer to about seventeen clicks to give one unit of blood. In a patient that is bleeding to death, that is not at all feasible. So, what happens is, now instead of doing the old system which didn’t have as many checks and balances, someone may avoid using the new system by working around it because no one that was an anesthesiologist, that is giving blood urgently to a hemorrhaging patient in an operating room, was at the meetings or was in the creation or design to say, “actually, this is not feasible. The patient will die while I’m trying to click seventeen times to give one unit of blood.” 

That is one example of something that has good intentions, but often doesn’t have implications of reality in the workplace – so then we have to work backwards to solve the problem. That is where we are often at in our healthcare system and it’s frustrating. It’s like what oftentimes happens when I work with people who write papers and I publish. I say ‘go write this paper’, but if I don’t give them clear guidelines and a structure and an outline of what I want, it is four times more work for me to write the paper. That is no one’s fault but my own.

That is where we are in our healthcare systems, we are often frustrated as end users of systems because we weren’t ever a part of the conversation. It’s really important that when we innovate that we bring in end users. They do this in the fashion industry all the time where they use models and life size people to try on the clothing before pushing it out, but we don’t often do that in healthcare, we don’t think about that. So, it’s really important that we involve the end users and people that are using the systems because they have the most insight as to what’s going to work and what’s not going to work. 

Dr. Shillcutt’s top 3 strategies to decrease physician burnout

HT: If you were in charge of a hospital or health system, what three strategies would you implement to decrease the incidents of physician burnout?

1. Involve C-suite to improve employee culture

Dr. Shillcutt: The first thing I would do is to make sure we had representation at the highest level, in the C-suite or executive representation, whose sole job was to constantly be working to improve the culture for our employees, and they would have leaders and resources in every department to do that because we don’t do that in healthcare. 

It’s not a one-person job. Everyone needs that representation in the microcultures and the divisions and the departments, but we need it in the C-Suite. So, when we are making decisions that are going to affect everyone in the institution, there is a voice there saying, “how is this going to affect the culture?”, because I think that is missing today. That’s the first thing I would do. 

2. Ensure the health of employees

The second thing, and this may seem very radical, but wouldn’t it be amazing if you as a healthcare employee, could come to your health system every day and be healthy? You had access to a gym, to a space to decompress for 15 minutes, to healthy food… We, as the healthcare workforce, don’t have access to those things. 

There was a study that showed most physicians working 12 hours a day; 67% don’t eat one meal in that time. Nurses and physicians are some of the unhealthiest people in our society. I know that would be radical, but wouldn’t it be amazing if you could go to work and leave healthy? It’s not rocket science, it makes sense, but it is a radical concept. It would be amazing. 

3. Ensure proper staffing models

The third thing is to make sure that there are proper staffing models because the reason people burn out is because they’re asked to do more in less time. We need support staff which is different in every area of medicine and you need to rethink how people work in their roles. 

Those are the three things that I would do first. 

Sasha Shillcutt, MD is a well-published researcher on gender equity, an award-winning physician, and a national educator and speaker. A board-certified cardiac anesthesiologist and tenured professor, she is the founder and CEO of Brave Enough, an organization dedicated to empowering others in their professional and personal lives to live authentically. She is a TED Talk speaker on Failing Forward and the author of Between Grit and Grace: The Art of Being Feminine and Formidable.