For many years when asked to describe my perfect job, I would say, “I’d like to be a corporate priest.” What I meant was that I could imagine a mental health professional being woven into the cultural fabric of an organization in a way that would allow her or him to become a familiar face to the people in the organization. Over time, the mental health professional would gain credibility for being both trustworthy and competent. Then, as events unfolded in the lives of the organization’s members — including when the emotional complications of life became too much — they would have a safe and confidential harbor to pull into, with a mental health professional who understood their world and possessed the skills to help.
In recent years, the U.S. military has begun to embed mental health professionals into its operational units, much as it does with medics. Of course, school and college counselors already operate from this embedded perspective on behalf of students, but not for faculty or staff. Certainly employee assistance counselors and psychologists provide services to employees, but generally these professionals are not visible in the everyday lives of the employees. Therefore, the comfort level that develops from familiarity is not possible.
Frankly, I didn’t know the concept of a corporate priest actually existed until I met Herdley O. Paolini. Herdley is the director of Physician Support Services (see below), a comprehensive counseling, coaching and leadership development program that provides services to more than 2,200 physicians and their families affiliated with the Florida Hospital system. Florida Hospital is a hospital organization with eight campuses and more than 2,400 beds for patients in Orlando, Fla. As detailed in “Antidotes to burnout: Fostering physician resiliency, well-being & holistic development,” an article posted on the web resource Medscape in April 2013, Physician Support Services “provides whole-person care through specialized professional resources aimed at maximizing the personal and professional well-being of Florida Hospital physicians and their families.”
Why embed in a culture?
Sometimes it is difficult for members of the general public to generate much empathy for the emotional and mental health needs of physicians. After all, the cultural mythology of physicians is that they sit at the top of the health care food chain and direct the efforts of many people while being handsomely compensated for their efforts. How difficult can that be? Is there really something about being a physician that presents special challenges and stressors?
The answer is a resounding yes … and increasingly so. Physician burnout, a phenomenon that directly affects quality of care, patient safety, treatment outcomes, patient satisfaction, nurse turnover, hospital staff morale and financial performance, is present at alarmingly high rates. A study published in the Oct. 8, 2012, edition of the Archives of Internal Medicine (now JAMA Internal Medicine) explored burnout rates by medical specialty and compared physicians with workers in other fields. The study revealed that job stress resulted in almost one of every two physicians experiencing burnout symptoms. The study’s conclusion was a compelling call to action: “Burnout is more common among physicians than among other U.S. workers. Physicians in specialties at the front line of care access seem to be at greatest risk.”
If doctors are at such risk, can’t they just go into the marketplace and obtain therapy? They can, and certainly they do. What is difficult, however, is finding mental health professionals who 1) understand the realities of the all-consuming work-life stressors that define the daily life of a physician and 2) appreciate the power of the physician ethos, which is best described as a belief system intentionally honed to create a sense of deep self-reliance, if not denial of their own humanity.
Physicians-in-training very quickly learn to not feel what they are feeling. As medical students and continuing through residency and fellowship, physicians are taught to tough it out and endure. Depression, illness and trauma are for patients … not for doctors. As a result, physicians are notoriously reluctant patients — and even more so when mental health is the issue.
Embedded in a physician culture
Exposure to trauma, both profound and chronic, in combination with constant personal sacrifice and unrelenting demands can place many physicians at risk for depression, anxiety disorders, anger issues, suicide, substance abuse and interpersonal conflicts. Inevitably, physicians become emotionally numb, often resulting in the depersonalization of patients. Thoughtful hospital administrators, physician leaders and physician advocates have long been aware of the stressors imposed on doctors. What to do about it, however, was always the open question.
This brings us back to Herdley O. Paolini and her small clinical staff. Ten years ago when Physician Support Services was established, Herdley was hired to create a program that physicians would utilize to help reduce the consequences inherent in the practice of medicine. She tells a very interesting story of how she went about embedding herself in the physician culture.
“I began by reading about the world of physicians,” she says. “I listened to the stories doctors told about their training, and I watched doctors interact with each other, other health care professionals and patients. In short, I came to learn about the physician ethos. I soon realized that physicians had their own special culture in the hospital and that if I was going to be helpful, I had to find a way to be accepted by members of the culture. To be accepted I needed face time with doctors — in their world.”
To accomplish this, she invested several months doing rounds with physicians, scrubbing in with surgeons and shadowing physicians in their office practices. She was there in the middle of the night as they responded to emergencies. She also qualified for medical staff membership by working emergency department call schedules. She was determined to be visible in as many venues as possible so physicians would come to know her as a human being and so that she could come to know them, their world and their language.
In time, members of the medical staff came to trust that she heard and understood them and that what was discussed would, in fact, remain confidential. Demand for her wise counsel grew rapidly. Today the service is highly utilized, often with a waiting list for nonemergency cases. More than 90 percent of the physicians in psychotherapy with the program at any given time are self-referrals.
In crisis and every day
The value of the embedded relationship was never more apparent than when, several years ago, a patient stalked and murdered a physician in the parking garage of Florida Hospital (see sidebar below). The Physician Support Services team was immediately activated. Attention was initially focused on the trauma experienced by the physicians and other medical personnel. Two hours after arriving, the Physician Support Services staff facilitated a support group for the transplant surgeons and medical students who had labored to save the life of their colleague. Nineteen surgeons gathered to share their shock, grief and fears and to remember their colleague and friend. Medical cultures in general and physicians in particular operate by the motto, “Illness (or trauma) does not belong to us.” As one surgeon explained, “[This tragedy] stripped away everything that I believed in and that held me together.”
That night and through the next six harrowing days, the clinical staff from Physician Support Services provided assistance to the widow and children of the slain physician. At the same time, in collaboration with a host of other mental health and spiritual caregivers, they assisted with trauma interventions for members of the entire hospital community. Predictably, these long days called on almost every clinical skill, including crisis debriefing, crisis intervention, grief counseling, consultation and group facilitation.
What was surprising, however, was the array of nonclinical skills and activities that were necessary. For example, lead administrators had great intentions but limited knowledge of the emotional needs of people during a crisis of this magnitude. Understandably, they were running on crisis mode and at times missed the multiplicity of needs on the ground. As a result, to be most helpful at this early stage of the unfolding crisis, the Physician Support Services staff had to communicate constantly, clearly and assertively with lead administrators and, at times, vigorously advocate for postcrisis best practices.
As the days unfolded, there were numerous opportunities for the Physician Support Services staff to assertively communicate, network, advocate, mediate, negotiate and recommend or access community resources. Fortunately, the respect and trust this embedded staff had established with physician leaders and hospital administrators made it possible to fulfill these nonclinical responsibilities.
Paolini expressed it best: “We are grateful that in this very difficult time, we were embedded in the medical staff and had previously established trust and credibility with both the medical staff and administration. This was crucial in our ability to deploy services with immediacy and to penetrate the various groups in a nonintrusive and welcomed way. We will continue to rely on these intentionally created dynamics to support the continued recovery and healing of the family, the medical community and the community at large.”
In terms of professional satisfaction, the rewards of being an embedded “corporate priest” revolve around knowing that your work makes a difference. This cannot be overstated. Every day at Physician Support Services, counselors are privileged to enter into an encounter with the physicians of Florida Hospital and their families. Every effort that is helpful to a physician has a ripple effect on his or her family, other health care professionals and, ultimately, on the patients served by this faith-based hospital system.
Successful embedding strategies
- Identify an organization champion: Secure a highly regarded champion within the organization who can provide access and endorse your credibility.
- Immerse yourself in the culture: Interview members of the culture, take people to breakfast or lunch, read about and observe the culture, and shadow members of the culture.
- Create opportunities for face time: Be as highly visible as possible in the organization, including attending meetings and engaging in informal chats at lunch.
- Build professional credibility: Make presentations and author articles or “think pieces” that speak to the felt needs of members of the culture.
- Don’t get co-opted by power: Be mindful that you need the blessing of formal power to function, but avoid being seen as an instrument of formal power.
- Avoid organizational politics: Whenever possible, avoid being perceived as taking sides.
- Advocate “for” not “against”: Advocate for the best interests of the people you serve, but do so in a way that is not against opposing views.
- Protect confidentiality: All is lost if your trust is compromised in any way.
- Navigate dual roles wisely: You inevitably will have multiple roles with members of the organization. These must be managed with utmost integrity.
- Appreciate your place: Never forget that you are an “inside outsider.” You will never be completely “in,” but you must be in enough to understand the perspectives and priorities in the culture.
Thursday evening, 5:45 p.m. My last counseling session ended 30 minutes ago. Two meetings, five clinical cases … it had been a typical day. I quickly responded to two “must return” emails and gathered the materials I needed to be ready for my 7:30 a.m. meeting the next day.
Physician Support Services is located on the edge of the hospital campus, near the Emergency Department, so it isn’t unusual to hear sirens, but I remember being vaguely aware of what sounded like a chorus of sirens. Without thinking much about it, I quickly selected items to include in my briefcase and headed home, just 10 minutes away.
I had been there only a few minutes when the phone rang. “There’s been a shooting in the parking garage … One of our doctors has been gravely wounded … in surgery … status of assailant unknown.”
I immediately alerted my team, and we all headed to the hospital. The victim was one of our surgeons; the assailant a former patient who stalked the doctor in the parking garage and shot him several times before committing suicide. Of course, in the beginning, all we knew was the identity of the physician. That knowledge was enough to understand that in all likelihood, the victim’s colleagues would be called upon to save his life.
The magnitude of the trauma was staggering. Before we arrived at the hospital, the tragic news came. The surgeon had not survived. The attacker who had been taken to another hospital in town was also pronounced dead. We were now in full-blown crisis mode. The enormity of the situation affected the hospital community at multiple levels: the family of the surgeon; the surgical team immediately involved; the medical colleagues of the surgeon; the larger medical, clinical and nonclinical staff; our patients; and the surrounding neighborhood.
Never in the history of the Physician Support Services program were we more thankful for the established relationships we had developed with so many members of our medical staff. The foundation of trust and credibility that we
had worked so hard to build would now be used to help our physicians cope
with this tragedy.
— Herdley O. Paolini, Ph.D., director of Physician Support Services at Florida Hospital
Physician Support Services
Physician Support Services at Florida Hospital was developed as a service that would be safe for and respectful of doctors — a place where doctors could access mental health services under their own initiative. Physician Support Services is much more than an employee assistance program for physicians. It provides an environment where physicians can grow and develop the human side of themselves, while also serving as a redemptive place to address their emotional and psychological fears and traumas.
The program offers self-referred individual, couples and family therapy for physicians and members of their immediate families. Medical staff leaders can also refer physicians for assessment and treatment. Additional clinical services include coaching for interpersonal effectiveness, human relations consultation and conflict resolution.
Physician development activities include continuing medical education (CME) units focused on physician self-awareness, emotional intelligence and leadership development. Some CME offerings involve retreat locations. For additional information, visit fhphysiciansupportservices.org.
Burt Bertram is a Florida licensed mental health counselor and licensed marriage and family therapist who provides clinical counseling to individuals, couples and families. In private practice in Orlando for more than 35 years, he also provides a range of consulting, facilitation, coaching and training services to a wide range of organizations, including Florida Hospital. He is an adjunct professor in the counseling program at Rollins College. Contact him at firstname.lastname@example.org.