The internet is flooded with tips on self-care, work-life balance, and 1,001 other ways to prevent burnout. While trying to reach Zen can generally help, we wanted to look at the problem from a different perspective. What if there was a management strategy that could reduce or completely eliminate burnout in the workplace? What if veterinary organizations could create an environment that keeps employees eternally happy?
Dr. Ivan Zak spent sleepless nights looking for an answer. He went through dozens of books, endless pages of research and scientific literature, consulted with industry luminaries, studied best practices from human healthcare, polled nearly 1500 veterinary professionals, and finally came to the conclusion – lean thinking is the solution.
What is lean thinking? Within the context of veterinary organizations, it’s a business methodology that helps unlock employee potential, gives decision-making freedom, and empowers and engages the team through bottom-up management.
As the burnout rate among veterinary professionals keeps skyrocketing and two-thirds of veterinarians don’t recommend the profession, we cannot remain silent.
We are gathering the brilliant minds of the animal and human healthcare worlds to discuss the possible solution.
Happy to share a transcript from our webinar “Lean thinking to reduce burnout: application in veterinary organizations. Learnings from human healthcare”. The conversation has been slightly edited for brevity and clarity.
We are answering questions from the audience at the end.
Welcome everybody. Thank you for gathering here to discuss the topic. We have an exciting group of people to kick this off with.
We’re going to talk about the burnout survey that I conducted in the healthcare industry. It was a part of my dissertation that I wrote trying to find a business solution to burnout in our industry. I’m happy to introduce our experts:
Thanks everybody for joining. We’re going to have an exciting conversation. We are going to talk about the findings that I have discovered through this survey.
We all know about burnout in the industry and I have experienced it myself as an emergency veterinarian, so the issue is close to heart.
In my study, I first wanted to quantify the problem and find out whether we are burned out or not, and then slice the data and see what other conclusions we can make. I used Professional Fulfillment Index, a tool developed at Stanford University. It was previously applied in human healthcare and compared to MBI which is a standard for burnout [Maslach Burnout Inventory].
I made three discoveries.
First, veterinarians are burned out. From zero to four: zero is “not at all” and four is “extremely.” The mean scores showed that the industry is generally burned out.
The second finding that we didn’t expect to make is that younger veterinarians (under 30 and in mid-30s) are more burned out than those who are at a later stage in their career. This is an interesting finding that I would like to discuss today.
The third finding that didn’t surprise me but I would like to re-visit, is that veterinarians are not the only professionals who have a risk of burning out. Especially in times like now, there is so much pressure on the technicians, and the study showed that they are more burned out compared to their colleagues in other roles.
This study was conducted right at the onset of the COVID-19 pandemic, so to identify whether the pandemic has made it even more stressful, we ran a poll with Stephen Cital’s help in the Anesthesia Nerds community. It was an alarming YES throughout the whole conversation there. [Veterinary Anesthesia Nerds is one of the biggest veterinary technician communities in North America. The poll showed that 78 percent of respondents have been feeling stressed out at work more than usual since the coronavirus pandemic started (1,120 out of 1,431 votes)].
I would like to open the discussion by asking Marie a question. First of all, you have visited us on the Veterinary Innovation podcast and I loved how you articulated the difference between burnout and compassion fatigue. Could you highlight that for us? And also, if you could give us your opinion on the correlation between age and burnout.
Sure, I’m happy to do that. Ivan. Thanks for having me as part of this incredible group of individuals and thanks for all the important work you’re doing. As you said, we both share passion for this topic.
A lot of the time, people use the terms burnout and compassion fatigue interchangeably. But, as we discussed, they’re indeed, very different things. The signs and symptoms can overlap for sure and it can be hard to deduce what a person may be experiencing. But it’s very important to recognize the difference, because the treatment is different.
Usually, compassion fatigue is a sense of exhaustion when we think about the work that we do as helpers. While any professional can feel burned out — you can be an engineer, a teacher, a parent who’s homeschooling right now — and you could feel burned out. But if you’re not in a caregiving profession, then you would not feel compassion fatigue.
Compassion fatigue stands from exhaustion from helping others so frequently and not giving back to ourselves. Veterinary social workers believe that compassion fatigue in a veterinary practice stands from repeated incidents of moral distress — those situations when we are put in a place where we really want to help but we can’t. This may be in this time of COVID; the situations when we are simply too short-staffed because half of the staff is out because of exposure to COVID and so we have to turn patients away. That would create an incident of moral distress when we’re doing something we shouldn’t be doing — we’re sending somebody away versus we want to see them. That scenario repeated over time leads to compassion fatigue.
People experiencing compassion fatigue not only feel unhappy when they’re at work, but they will also feel unhappy and distressed outside of work. It really tends to follow them home. In severe circumstances, it can be debilitating both in and outside of the workplace.
Burnout, as I said, can affect any professional. It’s that sense of exhaustion and depletion — both physically and emotionally — but it stems from the job itself. That can be from being pulled in different directions, being asked to do things that a person isn’t familiar with doing, or asking a person to do something they feel to be overqualified to do; that’s boring or monotonous. The key to burnout is that when a person is not at work, they’re not feeling those signs, they feel happy on the weekends or when they’re on vacation, but when it comes to going to work, they are dissatisfied.
So if you modify the workplace situation, then that burnout can be resolved. This solution would not work for compassion fatigue. You could remove yourself from that situation but once you go into another caregiving situation and you still are not taking care of yourself, then you will still experience the signs of compassion fatigue. I see a lot of people in the profession going from job to job thinking that things are going to be better, but because they’re not addressing the root of the problem or identifying the cause, they continue to experience those signs.
To answer your question about the age-related finding, it’s really interesting. When we look at other burnout studies and other demographics and look at age or years in the profession and satisfaction with work, usually satisfaction with work is at its lowest mid-career. People experience a mid-career crisis, just like some of us experience a midlife crisis; it can be seen as the same. It does seem from your study that happiness at work was really low in the younger professionals, and I’d be interested to hear what Stephen thinks about this. But I almost wonder whether people are going into the profession with these rose-colored glasses on; that they think that this is going to be rainbows and butterflies, puppies and kittens, and we get in and it’s hard. There’s a lot of things that we experience on a daily basis that we just didn’t anticipate having to deal with — whether it’s the clients, the caseload, or the medical records, or the monotony of some of the cases we might be seeing, or distress from the cases that may be far beyond our skill level.
I’m not sure if those are the reasons. There are so many different factors in play, but that would be my first inclination. Another guess is that maybe these individuals have not been around enough to cultivate the skills that would allow them to sustain themselves. It’s almost a little bit of population bias. When you survey these individuals who have been working in the profession for a long time, (the people who didn’t make it have been weeded out already), you are surveying people who have clearly done something right that allowed them to keep practicing veterinary medicine for 20-30 years. They have cultivated skills that have allowed them to do that.
Thank you for that. I think there are a lot of thoughts that come to mind. I think this finding opens an opportunity for further research.
I would like to shift gears to the second finding and ask Stephen to comment why it is that the technicians are actually more burned out than veterinarians. Is that something that we see in practice (I certainly did), and are we highlighting this enough?
Yes, thanks for having me again, and I’m happy to be the technician representative. I’m by no means an expert on any of this stuff. I’m so happy that Marie is here; she’s definitely an expert on the social aspect of this.
From personal experience, I can say — absolutely! A lot of these studies have been focused on veterinarians. We know that veterinarians have high suicide rates, high levels of compassion fatigue, and burnout. But just now, and thankfully with your survey, and there’s another survey done by Dr. Cohen, that is elucidating some of the burnout in technicians. It’s absolutely valid. I think there are extra layers on top for veterinary technicians, compared to what veterinarians have.
Veterinarians have this financial burden from school, especially this young demographic that we’ve been talking about — that’s super stressful. Technicians have this added layer of a stressed-out veterinarian on top of them. It’s not to complain about veterinarians; it’s just that we feed off their stress. We always talk about these owners with a stressed-out little Chihuahua, and we’re like, your dog is stressed out because you are stressed out, and then we get stressed out because you are stressed out. This is a horrible cycle that keeps happening over and over again.
There have been a couple of surveys out there looking at what can be done to help alleviate some of the burnout for technicians. Many of them attribute burnout to the monetary factor, which is indeed important, but the number one thing is that they feel unappreciated and not respected. And this is interesting. When you’re looking at some of these practice models and the ability to make money; when you use a technician to their fullest, the practice makes more money, the technician is happier, and we have less drama and less toxicity building up within the practice.
And there is a financial component. I think there is a self-sabotaging approach — especially younger veterinary technicians coming into the field have it — this ideology, “we don’t do it for the money.” Well, when I turn 30 and I live in San Jose in California, and I pay $2000 a month for a one-bedroom apartment, it becomes about the money eventually. So money turns out to put extra pressure on top of everything. We hear all this advice like “take care of yourself,” “go to yoga retreats,” “get a massage”… Well, I can’t afford a cheeseburger on a weekend because I’m not getting paid enough!
So the stress from not only being in a clinic (maybe the burnout comes from difficult clients or interpersonal complexities within the clinic) and maybe I’m enjoying the medicine part but it’s not being carried into my personal life because I don’t have the money to have fun and to live. That’s another big problem — that we, as an industry — need to solve for veterinary technicians. There have been a lot of discussions about unionization within the veterinary industry and that’s a whole other topic.
If practices really listened to these studies, really listened to their employees, the DVM, and the technician staff, and really implemented the guidelines that are being recommended, maybe we would have less movement towards these unionizations. The corporate companies especially, don’t really like these conversations. But then again, we have president-elect Joe Biden commenting on Twitter last year, saying that these corporate entities need to step off and allow their people to unionize.
Nancy Pelosi, Speaker of the United States House of Representatives, wrote a letter to one of these larger corporate hospitals telling them to support their staff appropriately. And just commentary (this is not verbatim, I’m paraphrasing), they were in talks with these technician groups that were trying to unionize to protect themselves, showing total disregard for those technicians. I believe there was something along the lines of “veterinary technicians is just a stepping stone profession or a career.” So if you’re invalidating what I’m doing, then I will probably not stay here for a long time or I probably won’t be loyal to you.
So the technicians have a very big weight on their shoulders; experiencing pressure from the big guys to get things done, or we’re feeding off their stress.
Something that really struck me is what Marie said about the difference between burnout and compassion fatigue. I thought, “Oh, I didn’t understand that very well, and I think I’ve gone through both.” But what’s funny about me particularly, is that I’ve always considered myself to be a strong person. For example, I never cried at euthanasia. I never thought I was really burned out until I lost my job at the end of April this year (largely due to COVID). This is when I realized I was really burned out and I had a manifestation of compassion fatigue. It was a wake-up call for me that I need to do better.
So to sum up, the lack of appreciation and lack of respect are the top reasons for burnout, followed by the money struggles. Obviously, we have some really bad hours sometimes. And again, there is a little bit of self-sabotage that we do as technicians, which can be compounded by the pressure of management, such as not taking breaks, not taking our lunches, trying to be the hero, and working through things. We need to stop doing that. We need to figure out what kind of life-balance activities we can do outside of work (that are cost-effective for us). In Cohen’s study about technicians and occupational burnout, there is a lot about non-monetary ways veterinary clinics can help their technicians with burnout in general. There is already evidence that money is not the biggest factor but if veterinary practices can pay for those yoga classes or massages — that would really help employees cope with burnout.
Thank you, Stephen, there is a lot to unpack there and I certainly can sign under every statement you made. Highlighting that is super important.
You mentioned not crying at euthanasia. You know, I always thought that it was my strength, but after I heard these definitions of compassion fatigue from Marie, I realized that it was not being strong, it was me being cynical and really not being sensitive anymore. I think my record was 12. It was Christmas day, and that’s the worst day of the year. This is when a lot of people come in with no money and you’re the bad guy asking for the payment for their pet.
So I would like to shift now to Bill. Bill has tremendous experience in both private practices and fastest-growing consolidations. My secret agenda behind this study was to see if consolidators are impacting the profession because subjectively, it felt like consolidation adds more stress. I surveyed professionals both from private and consolidated practices and haven’t revealed any statistically significant differences between their burnout rates. Bill, since you have hands-on experience in fast-growing organizations, have you seen an added stress while practices went through acquisition? What are the changes that can be done on the level of consolidation?
Sure, let me just first say thank you to Stephen and Marie. What you’re talking about and experiencing on a daily level is very real. I think that consolidators have a mandate to fix this. Stephen, you talked about unionization. It’s unknown whether it’s good or bad for the profession, but the compensation, the benefits, education, and respect for critical elements of the healthcare team is lacking. Marie, you talked about coping. Personally, as an ER vet and a business owner, the way I coped, was by leveraging the healthcare team to engage and empower them at every level. It was truly a team effort; it wasn’t the doctor-with-the-cape is a hero. It is hard work to find people who want that environment, who have the knowledge and have the capacity for it.
To answer your question, Ivan, I’m not surprised that there isn’t a statistical difference. Maybe without COVID, maybe with more data, you might have been able to see that there is a difference within a consolidator. Most of the stress that occurs post-acquisition is directed towards the seller, but more acutely, the practice manager or administrator or any of the leadership team involved in the business aspect of providing care. Those people within six-to-nine months’ post-acquisition, generally have their day job which already keeps them pretty busy, and now they have the job of working directly with a consolidator and their business teams. This is a significant stressor.
I’ve seen great successes when there was excellent alignment between the consolidator, the practice and the leadership team. Experiences there were wonderful; revenue went up, satisfaction went up, retention was great … And I’ve seen the opposite: lack of cultural understanding, lack of alignment and it becomes an unmitigated disaster where you have sellers leaving, and key doctors and nurses leaving. There have been clients calling consolidators at their home office (how they find the number I don’t know, but they do), sending them angry emails saying that they’ve basically destroyed the practice they loved. So there is a huge disparity.
Overall, consolidation is a work in progress. When I started Pathway in 2016, it was visionary. We wanted to elevate the veterinary technicians and the support staff. A part of it was based on the emotional intelligence that is generally lacking in the veterinary space. At Pathway, we worked to create awareness and training about conflict, to give employees the tools to cope with the day-to-day operation stress.
The act of consolidation itself created significant stress. And the biggest risk to consolidation is the loss of employees. We all know how hard it is to hire; we all know the cost of losing people. So if you think about it from the revenue point of view, not only do you lose a doctor, you lose revenue. If you’re losing a good veterinary technician, you’re losing revenue, you’re losing capacity, and you’re losing knowledge. And it’s not easily replaced because we don’t do a great job with having training sessions and systems. I’d love John to compare and contrast on the human side, where nurses are trained to certain standards. Veterinary technicians are too, but I think it’s less structured.
One of the things consolidators have to do now is offer stay bonuses. Literally. To get doctors and key people to stay, in addition to buying a practice, they pay a stay bonus. But it’s not an emotional connection; it’s a financial transaction which is not great. It increases the cost of acquisition and it also monetizes the relationship.
Another thing is benefits. One thing that people value more than compensation are the pet benefits and it basically would keep people in a bad situation because of their great pet benefits. The culture may be bad, the conditions may be bad, but people would stay because of the pet benefits. They would leave if they didn’t have them. Having a deep understanding of what binds people to the practice is really important.
Speaking of the leadership aspect … A practice owner may or may not be a good leader but they are there every day, shoulder to shoulder — in treatment, in the exam room, during triage. When you sell a practice, that day-to-day leader is not truly bought in. There is a gap in leadership. I think that consolidators are getting a little bit better and smarter about what practices they partner with, the structures they put in place and how important it is to retain that leadership and that control.
The other thing about the risk here is the loss of control. Veterinarians are very independent; they’ve been doing this for 20 or 30 years; they’ve built a successful business and now they’re selling for a lot of money. But the day they sign the contract, they’re losing control over their business and it’s scary. I experienced it. I was a co-founder of Pathway, then sold my part and continued as a chief operating officer. So I got to experience the whole spectrum. I know people who have experienced an emotional breakdown because of that; because they have lost their identity. That creates a lot of turmoil on the practice level.
Is consolidation a potential solution to fatigue and burnout, to the lack of quality pay? Can consolidation give veterinarians and veterinary nurses a better life? I believe yes. It has to. Because there is no way to buy all these practices and then to not have a happy, engaged, productive workforce. Just from the economic point of view, that is the direction it has to go in.
I see the progress. I see new consolidators putting effort towards creating a great environment. I also believe that the seller has a responsibility as well. They are making a lot of money, and they have an obligation to their team, to the consolidator, and to the profession. But too often, the seller is too tired. They got a lot of money, they want to take time off and they become very disengaged. The more the seller can be engaged in the process, typically, the better the outcome is for the team.
The last piece on this is about technology, systems, and processes. Once consolidators improve this segment of their business, the experience of practices post-acquisition will improve. The challenge is that they have the same bad systems that practices have. The clinical systems are poor, the business systems are marginal, and the processes are fragmented. It’s very difficult to provide meaningful support to hundreds of practices when you don’t have standardized systems, processes or metrics. Even communication … How do you communicate across thousands of people? These are fundamental business infrastructure pieces that are improving, and models are importing. I believe that lean thinking methodology — when you empower the frontline staff with knowledge and data, and responsibility — is really where veterinary consolidation needs to go and is going.
Thanks Bill, that was awesome. You actually gave two angles: from a person who sold a practice and a person who operated as a consolidator. So that leads us to John. John, I met you a year-and-a-half ago, and I was trying to explain what’s going on in the industry and you became a great inspiration for me to pursue this topic.
So this is the baseline, this is what the industry is dealing with, and with COVID on top, and human healthcare obviously, is suffering from it in many ways.
Marie was talking about burnout and compassion fatigue. Burnout can change with change of environment. And that’s my hope is: when the environment changes at work, then we can do something to improve that. And also, what Bill very well articulated, is that there is no WHY behind it.
Can you share what you have experienced and done in human healthcare and how it can relate to our field?
Thanks for having me, Ivan. It was really fascinating to listen to all of you so far. I’ve taken a few notes that I want to highlight.
“Pulled in too many directions”
“I’m overqualified to be doing some of the work I’m asked to do”
“My medical records are problematic for me”
“I’m under-appreciated and underutilized”
“I’m not actually paid for what I could possibly do”
To me, those are all the “why’s” the burnout exists. So the question is how do you take those problems, the ‘“why’s,” and what do you do with them? How are we going to improve the situation?
I look at your industry being about where our [human healthcare] industry was 15-18 years ago. I have been in this for 20 years, applying the principles of what we call organizational excellence in healthcare. These points you raised are exactly what we had in human healthcare.
Back to Marie’s point, anyone can run into these issues and burnout. When I became CEO of an integrated health system, I had the same questions that Bill has identified. How do I communicate when I run a place that has 7,000-8,000 employees? How do I make it better for all those people, realizing that they all have these same problems? What I’ve learned is that there is a way out of this and it starts with leadership — whether it’s the healthcare leadership or the administrative leadership. We really have to do things differently. We have to think differently as leaders. For this, you have to base the work that you do on a series of principles. The principles we’re talking about today, as they relate to burnout and compassion fatigue, all come back to respect for people.
Respect for people is one of the fundamental principles of this method of management. Some of these things take a lot to unpack. From a lean standpoint: I respect you, frontline worker, to identify and solve the problems in the practice. I don’t have to be in charge, as a lead clinician, to make all the decisions. Actually, what we want to do is make sure that you understand how to solve problems. We need to train you to understand how to do that.
Our role as leaders is to give up control, so to speak, to the people who do the work. When we give up control, that shows the ultimate respect. Back to Stephen’s point that “we’re not appreciated;” — Well, guess what? Those technicians can solve a lot of the problems that veterinarians have if we just let them. Because they actually have the ideas that will allow us to be more successful.
If you’re interested, you can go to https://shingo.org/shingo-model/, where there are 10 principles for organizational excellence. I’m only covering two of them today because they have the most to do with culture. We need to fundamentally understand the core principles behind building a culture of excellence. One of them is respect for people; the other one is leading with humility.
As leaders, we have to recognize that we don’t have all the answers. The people that we are counting on every day are the ones who have the answers. So when we give people the power to actually solve problems, it reduces burnout. That has been shown in a number of studies in human healthcare.
So whether you are running a private practice or a consolidator running multiple clinics, you need to think of the core principles that will help build a culture of excellence and reduce all the problems that you have defined.
I published an article in Harvard Business Review recently which talked about the principle of respect for people as it relates to the safety of the worker — something that we have a lot of issues with. When we think about respect for people and when we unpack that to the next level, what does it really mean? We need to keep our people safe. That is the ultimate respect.
The best practices to keeping people safe:
Another thing we need to think of as leaders: we don’t want to make frontline heroism an excuse not to act. We should have systems and processes that make it very clear that they don’t have to take risks; that they are involved in solving problems arising every day. If we create a system like that, then we know that things will get better from a workplace standpoint, and from emotional and safety standpoints. Obviously, there are going to be continuous problems, but if there’s a system to actually manage those problems, then we can do it immediately.
It doesn’t matter which industry you’re in. These principles are universal.
So as you are hearing these experiences that we are having, and considering how close our industries are, do you think we should follow the path that you paved in human healthcare in the veterinary domain?
I don’t know why this wouldn’t work in veterinary medicine. It seems that the problems you have in your industry are very similar. You have to run the experiment and you have to get some practices that are willing to go all in to try this methodology. It’s very successful when leadership is committed. If you really practice those principles — respect for people and lead with humility — I have never seen them not work.
Yes, I know it works in individual practices, I’ve seen it. Maybe it wasn’t called “lean” or “organizational excellence” but the principles you’re talking about work. The question is whether it can be done at scale and if consolidation can deliver that. The healthcare systems you were talking about are probably the analogy of consolidators in the veterinary space.
Even in our industry, this is not penetrated at the level that I had hoped. We did a study with UC Berkeley on the penetration of these principles. We found that only 10 percent of systems were actually applying them at scale and with the sophistication level that works. If you just do a little dabble here and a little dribble there, it doesn’t make a difference. You really need to have your entire focus on the methodology from top to bottom. Then it works at scale. It’s the commitment at the top that matters. We just published a book about it, Becoming the Change. If you’re not willing to change your behavior, then you shouldn’t even try this.
I have a question for you John. How hard is it for consolidators or managers to build this lean environment?
This is a learning by doing system. We have to persevere despite our failures. But if you have a system, then you can address these failures. There is a book called, Beyond Heroes, by Kim Barnas. It’s worth reading to understand what a standard management system is.
Another book I want to throw in is The Management of Men. It became a real inspiration for me.
So it’s the top of the hour and I want to thank everyone for contributing. Hope that we can approach this not only from a research and academic point of view but actually start taking practical steps. That’s what I’m inspired to do. Thank you!