September 15, 2015

Coming Down to the ICD-10 Wire: Avoiding Workplace Stress and Burnout

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EDITOR’S NOTE: The looming implementation of ICD-10 is bringing symptoms of workplace stress and burnout for healthcare professionals. So ICD10monitor recently asked nationally renowned psychiatrist H. Steven Moffic, MD for some timely advice. Dr. Moffic is an award-winning author and has blogs published by Behavioral Healthcare and Psychiatric Times.

 

ICD10monitor: Dr. Moffic, in your more-than-40-year career as a psychiatrist, you have also been an administrator of several large healthcare systems. And you have said that you became particularly concerned with the care and well-being of coders when they became over-represented among your patients when you were a tenured professor at the Medical College of Wisconsin.

How might what you were seeing then be amplified now as we come down to the wire with adopting ICD-10.

Moffic: First of all, Chuck, the important thing I learned, and it took me almost 40 years to firmly learn this, was that as a healthcare administrator and/or leader, that organizational level above the managerial one, your first ethical priority is not to patients, even if that sounds like sacrilege. And it is not to your organization, even if that is your employer. No, it is to your staff and employees, for it is their well-being and skills that help the patient and thereby help the organization to meet its societal mission. Patients can go elsewhere, but superb staff are hard to find and worth more than they are usually paid.

So, when I saw so many coders being overrepresented among my patients, I knew they were being taken for granted when they shouldn't have been. They were an essential piece for the financial well-being of the Medical College of Wisconsin. Yet they were overworked and under-appreciated, and sometimes harassed, often leading to burnout and depression. Psychiatric treatment could help many of these patients, but the system needed attention to lessen this kind of fallout. And some systematic changes have been made over recent years, including an extensive and available wellness program for all employees.

Now, as ICD-10 is about here, one of the challenges is: how will coders be treated? Obviously, they could be worked even harder and blamed when reimbursement is delayed or blocked. Those are essential ingredients for burnout. Or, they can be given time to learn what they have to about ICD-10, appreciate that they may naturally not be so efficient and effective at first, and thanked for whatever initial success is achieved. Of course, if a healthcare organization has relatively ignored the upcoming challenge, coders will not be ready.

ICD10monitor: What are the differences between workplace stress and burnout?

Moffic: I'm glad you brought those terms up together, "workplace stress" and "burnout," because they are often ill-defined and what they mean is interpreted differently by different people. They generally have different implications, but are best to be considered on a continuum.

Stress is generally part of daily life. Stress, in fact, is necessary for growth. It is part and parcel of anything unexpected or changed.

Stress is both subjective and objective. It is felt as a kind of tension or pressure or concern, and it can be detected by a faster pulse rate, increased perspiration (especially in men), and dilation of the pupils.

Stress, like so many things in life, is best in moderation, like in the Goldilocks story: porridge that is not too hot, nor too cold. That optimal amount and sweet spot of stress helps us learn new things, succeed on tests, and pay focused attention when necessary.

The only people who do not feel stress are the so-called sociopaths. These people have very little emotional response to anything and little empathy for others. Sure, sociopaths end up in incarceration, but many do succeed at work, sometimes leading large corporations – but they generally aren't good for the well-being of many who work for them.

On the other extreme, from too little stress to too much, when stress seems unremitting, then we can enter into the land of "burnout." For those who are visually oriented, burnout is like the aftermath of a spreading fire that depletes part of a forest; but in us, it is the hot flames of life that deplete us. In this imagery, stress is the amount of water, which way the wind is blowing, air temperature, and nutrients that affect the forest. At its best, with the stress removed, our forests can regenerate – as can burned-out staff.

ICD10monitor: What are some of the early signs of workplace stress and burnout that managers should be monitoring?

Moffic: First of all, managers have to be monitoring for this, not ignoring or looking away. In fact, at times, following a worker around or doing some of the job oneself to appreciate what goes into it can provide special insights into the conditions.

Then again, let's be clear that workplace stress can be normal and helpful at a certain level, frequency, and/or degree. However, it is when the stress evokes our natural physiological responses in the face of perceived danger that we can begin to see the warning signs – signs that tend to be different in men and women, though there is a range and overlap.

That is, men tend to have the classical fight-or-flight response, fueled by adrenaline. Evolution-wise, this made sense living on the land when danger to hunters could be ever-present. In our more "civilized" world, instead of a physical response, the threatened person may become more argumentative (fight) or withdrawn (flight).

Women tend to have more of a "tend-and-befriend" response to threat, perhaps fueled by the hormone oxytocin, so that they may seem more talkative and dependent than usual. With either gender, the result tends to be more mistakes and less efficiency.

Burnout, however, literally and figuratively can be spotted as workers lose their vitality, energy, and ability to bounce back from stress. When that occurs, workers will tend to come in late, try to take more breaks, and leave early. They tend to take more sick days.

ICD10monitor: What steps should be taken to avoid stress burnout by individuals and managers?

Moffic: The best strategy is prevention, to try to prevent that in the first place. That means not only avoiding too much chronic stress, but also having wellness programs in place. Managers should help put wellness programs into place in the workplace; individuals should also put their own wellness program into place, with or without a workplace program.

The basics and building blocks of wellness are eating well, sleeping well, and exercising. It means finding ways, even very brief, to relax, such as meditation. It means doing as much as possible that seems to fit one's authenticity and meaning for life. It means trying to find support in a good friend, a clergy (member) if religious, an intimate other, and a trusted workplace mentor.

Managers should try to keep stress, change, and expectations realistic. Support new learning and personal development, allowing for individual variation. Remember that one program does not fit all.

ICD10monitor: You and I have discussed this before, and that is this notion of perseverance in the face of adversity – this American trait of “keeping your chin up” or “plowing ahead,” even “biting the bullet.” Isn’t there an institutionalized stigma associated with admitting to one’s boss that you're burned out, for fear of reprisal or being fired?

It seems so. That's reflected in the fact that Americans have the least vacation time of any Western country and workers often don't even take what is available. Similarly, our unpaid and/or paid maternity and/or paternity time off is the worst, despite the crucial importance of parents being with their young infants.

In this age of increasing productivity demands and lack of job loyalty, there is indeed fear of losing one's job or role, even if that is not necessarily likely. Being prepared for that outcome can be helpful, including keeping one's options open as much as practically possible.

ICD10monitor: And might some of these early signs not be so obvious?

Moffic: What is often ignored or not connected to burnout are the medical symptoms or problems that are often related to burnout: headaches, stomach aches, frequent colds, and high blood pressure, among the most common. Sure, they can be indications of a medical problem that has nothing to do with work, but a proper medical evaluation can help distinguish that. Other indirect signs are increased alcohol or other substance use to try to calm down. Finally, there can be paradoxical reactions to observe: the worker trying to be even nicer, changing their office around, and even offering to volunteer to do more in a sort of unconscious denial of the stress.

ICD10monitor: How should one approach his or her boss?

Moffic: With apology and appreciation, not anger and antagonism. The boss is probably under too much pressure, too, as these are often systemic problems. If you can say how addressing burnout will improve the bottom line, that should get attention.

ICD10monitor: How should managers respond?

Moffic: They are the middle of the organization, so (they) should communicate both up and down to find solutions. They should champion wellness. Above all, they should treat employees with dignify, empathy, and compassion, no matter what.

Unfortunately, both undue stress and burnout may not be the end of the repercussions line here. Life-threatening stress can turn into its namesake, post-traumatic stress disorder (PTSD).

Burnout, by itself, is in ICD-10 as a healthcare condition of note, not necessarily needing formal psychiatric treatment. However, if one who is burned out then suffers a major loss, say of the job or a loved one, burnout may evolve into a major depressive disorder. Both these kinds of psychiatric disorders, or other related ones, will need referral to an EAP or outside source. The manager needs tact to not cause shame in making such recommendations. The last option is for the worker to leave that work stetting, but to do so with dignity intact and a lack of a desire for revenge.

Very gingerly, the manager might try to keep up with a worker's home life, for if there is too much stress there, that can feed back into the workplace. The solution, then, is for the worker to address the home front.

ICD10monitor: Finally, I receive so many emails from healthcare providers whose emails have quotes and sayings with uplifting messages. Are these what they are, or could these be signs of someone calling out for help?

Moffic: What an interesting observation and question, Chuck. I've seen some of those, too, and, at times, even used some of those quotes for what I write!

I think what they mean depends on the nature of the message, whether it is used for inspiration and meaning, or whether it is a call for help. One way to find out in a given situation is to comment back to the communication, commenting on what a fascinating saying or quote they used, and how did that come about?

Beyond answers to that, try to note what the content is saying and the emotional tone. If the words indicate some resignation, or the message doesn't fit the content of the communication, that could be a cry for help. Look for consistency, realism, and values. When the message is inconsistent with other communications (especially those little sayings that the organization uses itself), that may spell trouble. Of course, the most worrisome implication might be that someone is thinking of suicide and this can be reflected in sayings that convey a lack of hope.

 

EDITOR’S NOTE: Dr. Moffic recorded a series of “wellness” webcasts on how achieve mental health wellness. The series is available for downloading at the ICDuniversity Bookstore: http://shop.icd10monitor.com/SearchResults.asp?search=wellness&GO=GO

Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.

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