Advocacy Work: Antidote to Burnout

More than half of emergency medicine physicians suffer burnout, but Stephen Anderson, MD, FACEP, who practices at MultiCare Auburn Medical Center in suburban Seattle, isn’t one of them.

During his hospital shifts, he saves lives one at a time. During his off hours, he meets with school superintendents, mayors, governors, members of Congress, and anyone else in a position to change public policies to improve health and safety for the populations they serve.

“The surest way to make your own well-being better is to help others, and advocacy gives you the chance to do that on a huge scale,” Anderson says. “You can go out there and change the world.”

He is one of many physician leaders who find that advocacy work is an antidote to clinician burnout — a finding reported in an August 2018 article in The New England Journal of Medicine. The work can be time-consuming and frustrating; it can take time away from patient care and other responsibilities; and it may require using vacation days and a physician’s own financial resources, but enthusiasts say the rewards of advocacy efforts outweigh all that and, indeed, outweigh the frustrations of medical practice.

Donn Dexter, MD, FAAN, a neurologist and sleep medicine specialist with the Mayo Clinic Health System, finds that educating members of Congress about the need for research funding is empowering. He worked with colleagues at the American Academy of Neurology (AAN) and other physician organizations to push for the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, a National Institutes of Health-led partnership that is researching brain disorders such as Alzheimer’s and Parkinson’s diseases, depression, and traumatic brain injury. The initiative has invested more than $950 million to fund more than 500 projects since 2014.

His patients may never know of his efforts, Dexter says, but he knows the value of the work.

“I like to think that hundreds of millions of dollars of research translates into saved lives down the road for my patients with complex neurological disease,” he says.

A past president of his local medical society and a board member for the state society, Dexter has advocated for patients and physicians at all levels of government. He has helped start a state government relations team for Mayo Clinic Health System, met with state legislators at the Wisconsin Medical Society’s annual Doctors Day events, and organized a forum in which local physicians, healthcare leaders, and politicians met with the Congress members who represented their district.

He also regularly participates in annual Neurology on the Hill events sponsored by the AAN. Last year, 214 neurologists from 48 states convened in Washington, D.C., to educate lawmakers about the dangers of step therapy in certain situations, the need for more NIH funding, and other matters.

“Being around that group of people [who] have this incredible passion and knowledge about advocacy, it couldn’t help but rub off on you,” he says. “You just come back energized. Being involved ... is a powerful way to transform your understanding of your role in society. It’s a powerful antidote to burnout — I truly believe that.”

How To Be Heard

One well-known driver of physician burnout is loss of autonomy. The government, insurance companies, and health system administrators tell physicians what to do and how to do it and, in many cases, compliance is not optional.

“When you take away physicians’ choices in taking care of their patients after they spent all these years training, they can get very frustrated,” says Ross F. Goldberg, MD, FACS, president-elect of the Arizona Medical Association. “Advocacy is a way for me to get involved and say, ‘Look, you can’t make this decision on your own; I have to be a part of it.’ ”

Goldberg, a general surgeon, is vice-chair of surgery at Valleywise Health in Phoenix. He chairs the American College of Surgeons’ Health Policy Advisory Council and serves on the ACS Board of Governors and its Legislative Committee. He also chairs the Advocacy and Health Policy Committee of the Society of American Gastrointestinal and Endoscopic Surgeons and serves on its board of governors.

Consequently, he was well-positioned in 2017 to help craft state legislation addressing the opioid epidemic. The state Medicaid program sought his input about exceptions to the strict limits on opioid prescriptions that had been proposed. He helped write the surgeon-prescription guidelines included in the Arizona Opioid Epidemic Act that went into effect last year.

“I was not the only one — obviously our lobbyists and other physicians were working on it — but some of the exceptions in that law were written by me or taken from other places and introduced through me,” he says. “It feels great to have had that kind of effect in the state of Arizona on such an important issue.”

Through his advocacy work at the state and federal levels, Goldberg has sharpened the leadership skills needed to be an effective advocate within his own health system.

“It’s a very cool feeling to be able to reach out to the CEO and chief medical officer of your institution and say, ‘I need to have a conversation,’ ” he says. “They’re willing to listen, and willing to act upon my input if it’s reasonable. That does help prevent burnout because I know I can enact change.”

Melissa S. Dillmon, MD, a hematologist/oncologist at the Harbin Clinic in Rome, Georgia, chairs the Association for Clinical Oncology’s Governmental Relations Committee. She typically devotes one day a week to advocacy work. Like Goldberg and most other physician advocates, she is not reimbursed for her time away from the office.

“It’s time away from my family and definitely there is a monetary cost, but it keeps me passionate about what I do,” she says. “Being involved positively in change, although it may be slow, makes me hopeful that I will be able to maintain at least some of what I went into medicine for, which is the interaction between me and a patient and the ability to make a difference in their lives.”

Increased funding for National Cancer Institute-sponsored research is Dillmon’s most satisfying success at the federal level. Closer to home, she pushed for state legislation in Georgia that forbids pharmacy benefit managers from mandating the use of mail-order pharmacies, which are associated with the wrong drugs or wrong doses and delayed delivery, all of which potentially hurt patient care.

“A lot of my patients are fearful of what the future holds and whether or not they will be able to receive the treatment that they need and that they deserve,” she says. “So when I tell them about why I’m going to D.C. or why I’m going to Atlanta and what I’m advocating for, it makes them feel hopeful.”

Making A Difference

The emergence of the patient-centered medical home has transformed care delivery — for patients and clinicians — in the past 15 years. Rheumatologist Robert McLean, MD, FACP, president of the American College of Physicians, helped give it birth.

As chair of the Health and Public Policy Committee for ACP’s Connecticut chapter in the mid-2000s, McLean was having dinner with U.S. Rep. Nancy Johnson, R-Connecticut, an influential health legislator at that time, as part of his routine relationship-building activities. The ACP had recently developed a policy paper describing the potential merits of the medical home model, and McLean handed Johnson a copy. “It wasn’t really a topic of the evening, but I said, ‘You might be interested in reading this in your free time,’ ” he remembers.

A few weeks later, the congresswoman called a hearing on the topic of the advanced medical home, as it was then called, and invited the ACP to testify before the subcommittee. That led to early funding to pilot the concept, which in turn led to broad federal support — and support from private insurers — for the medical home care model.

“When you have instances where your presence or activity really made a difference, you feel ‘I need more of this because I feel so good about it,’ ” says McLean, medical director of clinical quality for Northeast Medical Group, an affiliate of Yale New Haven Health.

Such big wins are rare; advocacy work is usually tedious and slow. Early in his career, McLean learned the value of having good relationships with policymakers and being present when they are learning, discussing, and considering issues that will affect physicians and their patients. That became clear to him when nurse practitioners lobbied to be allowed to practice independently in Connecticut and, for the first time, he met with legislators to share the ACP’s perspective.

“I quickly realized that, if the physician voice was not there at certain times, other healthcare voices that may not have had the physician interest — or, quite frankly, the patient interest — in mind would have more influence,” he says. “You need to be there, and I came to realize that being in the process is very empowering.”

That provides balance from the frustrations of medical practice today. “While I have the same dysfunctions of the system when I’m seeing patients, these other activities are empowering because they make me feel like I can — and in fact, I do — make a difference,” he says.

Help Others, Help Yourself

During his residency, Anderson was trained to create a hard boundary between his work with patients and his life outside the hospital.

“We’re taught early in our medical training in emergency medicine that, to not burn out, you have to leave the day behind as best you can when you walk out the doors,” he says. “And then we are told that whatever is going on in our personal lives, we have to leave it at the door when we come to work.”

Anderson, immediate past chair of the American College of Emergency Physicians, ignored that advice, and that has worked to his benefit and to the benefit of others. Throughout his career, the crises that bring patients to the emergency department have become his advocacy initiatives.

Frustrated that schools in Washington state were no longer teaching cardiopulmonary resuscitation, he took action. “We went out and had a fundraiser and put defibrillators on the wall of every school,” Anderson says. “And then, we got the CPR curriculum back in schools — a one-hour class that’s taught in every junior high and high school in Washington state, so that, by the time they graduate, people have been trained in CPR twice.”

Frustrated by America’s ongoing mental health care crisis, Anderson worked with the mayor of his hometown to develop a one-hour course for students — Real Emergency Aid Depends on You (READY) — designed to eliminate the stigma associated with mental health problems and teach basic skills to use during a mental health crisis.

Frustrated by the increasing number of drug overdoses coming into the emergency department, he started working nearly a decade ago to find solutions to the opioid crisis. One strategy is equipping every police vehicle in his local community with naloxone, the opioid antagonist used to counter the effects of overdose.

When Anderson’s daughter Kayce overdosed on heroin a few years later, a police officer used a naloxone kit to save her life.

“The first time your daughter ever gets resuscitated with naloxone you start to realize that this is a drug that really...needs to be every place where people might need it,” he says. “Now naloxone through political actions that I have been a very big advocate for, is available over-the-counter in Washington state so that anybody [who] might need it to save a life can have access to it.”

When a travel delay prevented his daughter from starting a rehabilitation program on the day planned, Anderson found himself driving her to a dealer’s house to get through the night. Medication-assisted treatment — using buprenorphine and other medicines to support withdrawal — was not available at the emergency department. “After Kayce got on the plane the next morning and started in her rehab, I got very active,” he says. “If people want help, they should be able to turn to the emergency department.”

Anderson’s daughter died in early 2019; last fall, he was using his days off work to help get a statewide medication-assisted treatment program in Alaska. “And I was in Denver last week trying to make a difference, and in Utah before that, trying to make a difference,” he said in a telephone interview. “If you’re passionate enough and you’ve got a story that people will bond to, you get people’s ears, and you give people a chance to make the world a safer and a better place.”

Reference

1. Eisenstein L. To Fight Burnout, Organize. N Engl J Med 2018; 379:509-11.