Blog post by Robert J. Mahoney, M.D., SFHM and Chuck Webster, M.D., M.S.

Like to a bad physician
Fallen sick, thou’rt out of heart: nor cans’t prescribe
For thine own case the draught to make thee sound.

                               – Aeschylus, Prometheus Bound

Since the term burnout first became popular in the late 1970’s, healthcare providers and executives have struggled to find ways to combat what appears to be a growing epidemic. As defined by Christina Maslach, burnout is a psychological syndrome in response to job stressors consisting of three primary components: exhaustion, cynicism, and ineffectiveness. A systematic review of studies examining burnout prevalence published in JAMA in September concluded it is difficult even to determine how prevalent burnout is, with rates varying from 0% to 80% depending on the criteria used.

To prevent burnout, professional societies (including the U.S. Accreditation Council for Graduate Medical Education) have attempted solutions such as reducing duty hours—though there is limited evidence that such efforts have been effective. Nonetheless, physicians may be reducing their work hours in an attempt to fend off burnout. Other strategies, particularly those in popular media, tend to focus on self-care behaviors people can engage in to reduce their chances of burnout – presumably to increase their resilience. However, it is not entirely clear that a deficiency of resilience underlies burnout, or that increasing it can prevent burnout.

What if, along with culture change, self-help efforts, and enforcing an appropriate workload, we were to explore ways in which our workflow itself can be improved to prevent burnout?

One approach is to look at the concept of “flow”, a state that is possibly the exact opposite of burnout. The concept arises from the research of psychologist Mihaly Csíkszentmihályi into the “optimal experience” – an immersive state of deep concentration achieved by diverse groups: musicians, climbers, sailors, athletes, and others. The concept is most completely developed in Csíkszentmihályi’s book Flow: The Psychology of Optimal Experience. Although the individual experiences themselves are different, there are specific components that the flow state has in common for each activity:

  1. The activity is challenging and requires appropriate skills
  2. The activity requires an individual’s full concentration and undivided attention
  3. The activity has clear goals and provides immediate feedback
  4. The activity involves a perception (if not reality) of control
  5. Engaging in the activity involves a loss of self-consciousness and self-awareness
  6. Engaging in the activity usually involves a loss of time-awareness as well

According to Csíkszentmihályi, flow experiences are:

situations in which attention can be freely invested to achieve a person’s goals, because there is no disorder to straighten out, no threat for the self to defend against. We have called this state the flow experience, because this is the term many of the people we interviewed had used in their descriptions of how it felt to be in top form: ‘It was like floating,’ ‘I was carried on by the flow.’ It is the opposite of psychic entropy—in fact, it is sometimes called negentropy—and those who attain it develop a stronger, more confident self, because more of their psychic energy has been invested successfully in goals they themselves had chosen to pursue.

– Csíkszentmihályi, 2008

Although seeing patients, reading films, studying pathology slides, or performing surgery may not always be as exhilarating as climbing a mountain or performing a solo, there may be components we can borrow from the flow experience, even in the most stressful situations, to reduce the likelihood that physicians will go on to develop burnout.

– Robert J. Mahoney, M.D., SFHM

Dr. Mahoney has zeroed in on one of the most fascinating aspects of workflow, the way it determines subjective user experience. I’ve seen hundreds of definitions of workflow, some paragraphs long. But my favorite is a “series of steps, consuming resources, achieving goals,” where “steps” can be replaced by “tasks”, screens”, “activities”, or even “experiences.”

Several years ago I wrote one of my favorite blog posts ever, “From Powerless To Powerful In Healthcare Through Workflow“, in which I also invoked Mihály Csíkszentmihályi’s concept of flow as a psychological experience. Flow is:

the mental state of operation in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity.

So what I’d like to pose is three “levels” to consider Dr. Mahoney’s excellent HCLDR questions below:

1. How do Dr. Mahoney’s HCLDR questions apply to you? What is your personal experience with managing your environment and mental state so you can achieve flow?

2. Given our current state of EHR and health IT software and technology, such as it is, how can we help physicians, patients, and other users achieve flow-like experiences?

3. Finally, how might we change the fundamental design of EHRs and health IT to better manage interruptions, provide feedback, increase efficiency, and achieve perceived and actual user control over their work and workflow?

By the way, I’d like to share a personal anecdote. I used to have occasional lunch with one of Csíkszentmihályi’s graduate students. Csíkszentmihályi was studying teenagers growing up in Chicago. A timer would go off randomly, and the “subject” was to enter into a diary the time, what they were doing, and what they were thinking and feeling. Farid’s job was to read and code the diaries into a database for analysis. He mentioned to me an entry (without identifying anyone, of course!) in which the young man wrote it was Saturday night, he was sitting on a porch with his girlfriend, and, well, as to what he was thinking, he wrote, “What do you think I’m thinking?” And we laughed, and the grad student said, I know what he’s saying, but how am I supposed to code it!

The reason I mention this is that Csíkszentmihályi was the first researcher to use “ecological momentary assessment.” Today, variations of it have become a standard research methodology, though, as you can imagine, the technology to capture this data is considerably advanced (wearables, wireless communication, natural language processing, machine learning, etc.). Just think of the possibilities for studying not just workflow, but life-flow!

Thank you to Dr. Mahoney for inviting me to collaborate with you about one of my favorite topics: Workflow!

See you at the HCLDR tweetchat!

– Chuck Webster, M.D., M.S.

Please join us Tuesday January 22nd at 8:30pm ET (for your local time click here) when we will discuss how to improve the flow in modern medicine – specifically these four areas:

  • T1 What can healthcare organizations do to limit interruptions?
  • T2 What can healthcare organizations do to give you better/more immediate feedback?
  • T3: What can healthcare organizations do to improve your efficiency?
  • T4: What can healthcare organizations do to increase your actual/perceived control?

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