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The three-legged stool approach to physician burnout


Team-based communication and an emphasis on personal resilience have improved one medical system’s employee engagement by more than 20%.

Approximately two years ago, when Mission Health in Asheville, North Carolina, gave their standard employee engagement survey, only 17.5% reported being “fully engaged.” That’s “where everybody’s really onboard, believes in the mission and engaged in their daily work,” says Ronald A. Paulus, MD, president and chief executive officer.

After implementing a three-pronged approach, just a year and a half later, 40% of employees reported being fully engaged. “It was a dramatic change,” Paulus, a former practicing internist, told Medical Economics.

They achieved this by rolling out what Paulus describes as “a three-legged stool.”

Increasing team engagement

Based on the work of Marcus Buckingham, a lead researcher for Gallup polls, and author of the book StandOut 2.0, Paulus and colleagues took to heart the advice that “you can separate out high-performing teams from low-performing teams by how frequently they interact, and how often individuals get to work in their areas of strength,” Paulus explains.

Using an app derived from the Strengths Finder book, which “elucidates your main strengths,” he says, each team member checks in with their team leader at the beginning of every week. A team leader is not necessarily one’s boss, either. “Teams are dynamic; they form and re-form\ and so forth,”

Each week, the team leader asks each team-member three things: what they need from the team leader, what they loved about their week and what they loathed. “That gives you insights into the highs and lows, and allows you to redirect people out of the lows,” Paulus says.

Then they list their priorities for the week. The team leader might help them to change these if needed.

Lastly, they rate themselves on two characteristics:
• How much value do I feel like I contributed last week?
• How much did I get to work in my strengths last week?

This creates a kind of “real-time, concurrent view of an employee engagement survey,” Paulus says, that allows team leaders to observe and comment. This “continuous feedback” is the first, most important leg of the stool.

Next: Reducing hassles


Reducing hassles, increasing joys

Leg two, which they call “Mission Renew,” is about “systematically improving the work environment” by shadowing employees to “collect and amalgamate their hassles and joys,” Paulus says. Then they do their best to eliminate the hassles and “upscale” the joys.

In many cases, the hassles derive predominantly from information technology, such as electronic health record (EHR) systems, but sometimes, he says, it’s a mundane hassle, “such as this printer always has streaks on it.”

Sometimes this part of the process reveals that people are not working where their strengths are, and particularly for non-physicians, they have crated a path in their career development center just to retrain people who love the company, but not their individual job responsibilities.


The final leg of the stool revolves around helping all team members to cultivate “individual resilience,” an approach they take from a company called Life XT, a productivity program that works with various organizations. The founders wrote a book called Start Here that provides a prescription “using scientific evidence for resilience by drawing on common characteristics in other cultures such as meditation, gratitude and engagement in activities beyond the self,” Paulus says.

However, he makes clear that the individual is never left to figure it out for themselves alone. “We try to look at all three legs because to put it all on the individual and say ‘You just need to become more resilient’ is sort of like blaming the person for the world being screwed up around them.”

While none of these three legs are perfect, they’ve had a profound impact on Mission Health’s burnout rates, which he compares to “light showing through the blinds.”

 “I think the sense of movement creates hope, hope creates energy and energy creates problem-solving,” Paulus says.

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