Burnout in the O&P Workplace: Recognizing, Understanding, and Preventing

Numerous surveys and studies have shown that not only is occupational stress the major source of burnout among professional adults, but it has escalated progressively over the last few decades, according to the American Institute of Stress. A survey, Stress in America 2017, by the American Psychological Association (APA) showed that 61 percent of Americans have work-related stress and three out of four Americans reported experiencing at least one stress symptom within the last month. According to the APA survey, 45 percent of those surveyed reported insomnia, 36 percent said they felt nervous or anxious, 35 percent reported feeling irritable and angry, and 34 percent felt fatigue due to stress. The signs and symptoms of burnout are as prominent in the O&P workplace as in any other profession. Errors, fatigue, complaining, agitation, displacement activities (doing something that may be easy or entertaining to distract from something more stressful), compassion fatigue, tardiness, calling in sick frequently, or needing time off are classic indicators of burnout on the job. "What needs to be understood is that life has changed over the last 15 years. Everything moves faster and there are multiple inputs of data constantly, and people are constantly distracted and have loss of focus," says Joyce Perrone, a consulting partner at Promise Consulting and director of business development for De La Torre Orthotics & Prosthetics, Pittsburgh. "Burnout is another word for stress. We all need to get better at understanding what is a stressor at the workplace, then process how to relieve those situations." Contributing Factors

The factors of burnout in the O&P workplace are as numerous as they are diverse, clinicians say. According to Frank Snell, CPO/L, FAAOP, president of Snell Prosthetics & Orthotics, Little Rock, Arkansas, a company's administrative staff has one of the most difficult positions as the first line of defense in making a good impression. "They are the ones who have to preauthorize insurance benefits, enter all the data in the electronic medical records, and then hand the patient off to the practitioner in record time and with no mistakes," says Snell, who is the third generation in the 107-year-old business. "They are an overlooked part of the O&P pie and need to be recognized for their importance." Changes in technology can also contribute to burnout and increase stress levels on the job. "Not everyone in the work environment is tech savvy," Perrone says. "It adds an extra burden when a tool you now have to use daily is something you're not [confident about using]. Some people now have to type and they're slow. So many factors start going into the crucible of patient care that slows the process down and frustration and burnout can occur." Another widespread contributing factor for stress in the O&P work setting is the constant battle of addressing ever-increasing and continuously changing regulatory requirements. "Insurance company demands have increased tenfold for documentation," Perrone says. "This has caused greater demands to assure every ‘i' is dotted—not twice, but three or four times." Even if a company is staffed with a quality support team, "the clinician may have increased pressure even from within to assure compliance is met," Perrone says. Activities that pull practitioners away from their inspiration for pursuing the O&P profession can also contribute to burnout. As with other healthcare professionals, most prosthetists and orthotists enter the profession to help better the lives of those who are physically changed, says Bruce "Mac" McClellan, CPO/L, FISPO, FAAOP, president of Prosthetic Orthotic Associates, Tyler, Texas. "It is where our heart and soul lie," says McClellan, who has worked in O&P for nearly five decades. In addition to still practicing full time, he has also served on numerous boards and worked in hospital and academic settings. "In decades past, patient care was our primary focus, and we were able to concentrate our time and effort toward that objective," he says. With the advent and development of L-Codes, and the constraints that accompany these billing requirements, "the government, and thus the insurance companies, have encircled us with an ever-shrinking noose of control with regard to documentation requirements and funding restrictions," McClellan says. Such regulations have made it not only increasingly difficult for O&P companies to remain profitable, but also has detracted from the clinicians' ability to provide quality care, McClellan says. "We're limited in the time that we can spend with them," he says. "That time which had previously been spent designing, fine-tuning, educating, training, and simply providing personalized care has been stolen away from patients by requiring practitioners to justify everything we do to obtain reimbursement for the services we provide." Compassion Fatigue

Brian Kaluf, BSE, CP, FAAOP, came to O&P from a biomedical engineering background. He has been the clinical outcomes and research director for Ability Prosthetics & Orthotics, Exton, Pennsylvania, since 2011. His current role is directly related to fostering a workplace environment that addresses burnout. He says compassion fatigue can be an immense contributor to stress in the workplace. "My fellow CPOs are incredibly passionate about their profession and care deeply for the patients they treat," he says. "We put our heart and soul into our practices and this can leave practitioners particularly vulnerable to burnout when environmental constraints, patient compliance, or regulation/policies limit our ability to achieve an optimal result." Nina Bondre, CPO, started working at Dankmeyer Prosthetics & Orthotics, Linthicum, Maryland, in 2017, but her love for O&P began while she was still in high school. She concurs with Kaluf. "Some factors that can cause burnout are also our strengths," she says. Practitioners have a strong desire to take care of their patients, Bondre believes. "We want to do what's best for them, but getting what's best for them can often be a challenge with particular insurance coverage," says Bondre, who works primarily with spinal cord injury and pediatric orthotic patients. "We also have compassion for our patients, which often results in squeezing them into our schedule because we know it will help them. But that can cause tiring schedules for clinicians." Finding Balance: An Employee Perspective

Perhaps the best way clinicians can mitigate stress in the office setting is to set realistic personal boundaries and expectations at work. "Clinicians now need to balance O&P care with efficiency and accuracy complete with all documentation, education, and skills to assure a long-term successful outcome for the patient. All of the team must do their part of the work for this to happen," Snell says. "This involves training, cross-training, and awareness of the overall goal of being your best and meeting the needs of the patient. When a portion of this fails, everything is compromised." Being realistic about a practitioner's time and energy is important, Bondre says. "You won't do a good job taking care of your patients if you're mentally drained or physically exhausted," she says. "Setting limits for yourself on when you can see patients can help make sure you are producing quality work and taking care of your patients." When it comes to managing emotions and optimism in working with patients to manage a chronic disease state, practitioners need to possess "a bit of reservation," says Kaluf. "We are so fortunate to have the opportunities to make a positive impact in the mobility and quality of life of our patients, but in the infrequent instances when our expected outcomes are not achieved, the letdown can overshadow the routine successes we experience," he says. "By accepting a viewpoint that what we do is difficult and involves many variables, practi-tioners can hopefully dampen the emotional highs and lows and conserve their emotional reserve to last a busy week in the clinic as well as a long and successful career." Finding Balance: A Management Perspective

One role of a manager or company owner is to ensure that the team is prepared to do their part—that means adequate staffing, an emphasis on teamwork, and shared responsibility are critical for a successful business, Snell says. "In today's O&P world there is a significant manpower shortage putting a very real constraint on quality patient care." Management can address this in various ways, Snell says, by using care extenders, considering limiting its scope of practice, or eliminating certain procedures where encroachment from other businesses has become more prevalent, such as with diabetic shoes or compression stockings. "We cannot compete with Walmart by paying a CPO to apply a Velcro over-the-counter wrist splint," Snell says. Management also can't wait until the end of a billing cycle to engage with their staff, Kaluf says. "All too often the cadence of engagement with management increases toward the end of a billing cycle, as progress to meeting financial projections or performance goals can dominate the focus of attention," he says. The result is a Slinky effect, Kaluf says. "Practitioners are stretched and compressed through messaging from management and even [through] control of their appointment scheduling." Management teams also focus on "best-case and worst-case patient encounters," Kaluf says. "Management and administrative teams typically engage with practitioners mostly to intervene concerning patient complaints and lulls in profitability, or to oversee provision of expensive interventions [such as] microprocessor knees." Management needs to be humble and approachable and keep the lines of communication open, Bondre and Perrone say. "Encouraging communication is key," Bondre says. "If employees are comfortable communicating with their supervisors, they can start to work toward solutions." Leaders have to lead with alacrity, Perrone adds. "Often the language is the key. When leaders act like doomsday and the sky is falling all the time, it drags the team down," she says. "No team wants Eeyore at the helm." Companies also need to build fun celebrations into the work setting not only at Christmas, but throughout the year, Perrone says. "Leaders need to encourage fun at the workplace. What if they went around the office with ice cream or pizza or gift cards as a surprise?" she says. Management could also consider giving spontaneous small gifts when an employee does well, perhaps, with a challenging patient or an insurance rep, Perrone says. "If management shows up consistently with purpose, in a good way, it can lift staff up emotionally. If the purpose is just on profits, that will never sustain. Have a greater purpose as a company and as individuals." In addition, McClellan says, having everyone invested in the company's process by recognizing their individual importance to the overall success of the practice, as well as patient outcomes, is paramount. "By having regularly scheduled staff meetings to review the status of patients in the system, everyone gets on the same page, which helps reduce inefficiencies and frustration," says McClellan, who believes good lines of communication between practitioner and office and technical staff are also important. "If these don't exist or become fuzzy, it can lead to a loss of continuity and an effective operation, which no one enjoys." Burnout, Past and Present

Much has changed about the O&P landscape in the last 15 years or so as it relates to professional burnout. "As practitioners, we used to do three things: patient care, documentation, and fabrication," says Snell, who started working in the family business when he was 14 and was a certified prosthetist/orthotist by the time he was 22. "Today we only seem to have time for two, so take your pick which two you need to do and delegate the other." The Centers for Medicare & Medicaid Services (CMS) and other third party payers are the primary driving force behind this stress, Snell says. "The fear of audits and litigation are some of the most stressful things we face," he says. According to Kaluf, "an undeniable force" that has contributed to burnout and compassion fatigue in O&P has been the rampant auditing and inconsistent insurance policies, which can leave a practitioner spent. "I have spoken with veteran practitioners who elect to retire from the profession as they consider the current level of insurance scrutiny and bureaucratic tedium intolerable," he says. McClellan agrees. "This quantum change in the healthcare realm has significantly affected our ability to provide the type of patient care we could in the past. It has become a major source of frustration to patient-oriented practitioners and is a major contributor to burnout," McClellan says. "It has also caused premature retirement of some extremely gifted patient care providers across the healthcare spectrum who didn't want to, or couldn't, make the switch to a third-party-payer-dominated healthcare system and the demands that it placed on them." Self-care, Fee-for-value On the Horizon?

Some practitioners agree that within the coming decade, in response to more demands from healthcare professionals, a trend toward self-care and mindfulness is emerging. "As people learn to take care of themselves, they will become better at saying no and managing their own time and stress levels," Bondre says. The drive from within the healthcare environment and from external pressures to migrate to a fee-for-value payment structure can provide a unique opportunity for the O&P profession, according to Kaluf. By aligning reimbursement and performance indicators to patient clinical outcomes and quality, many of the current frustrations that lead to compassion fatigue and burnout can be alleviated, he says. "If fee-for-value payment structures can simplify the regulatory and reimbursement environment, new O&P business models will evolve that incentivize practitioners to focus on what they entered the profession to do, provide compassionate O&P care to their patients." Kaluf says Ability P&O is confident the future of O&P reimbursement will go the way of fee-for-value and has been preparing for the inevitable. Ability has developed models and simulated payment structures based on quality that have been implemented by CMS for reimbursement to other healthcare providers such as physicians, nurse practitioners, nurses, and soon to physical and occupational therapists, Kaluf says. The next decade will also likely be a time of creativity and exploration, and the future of O&P care will rely on today's innovators who can harness clinical outcome data and who aren't afraid to take chances on new ways to care for patients, Kaluf says. "If my predictions are realized, I see a future that can improve the value of care to patients and simultaneously provide an engaging workplace environment that [can] bring the best out of O&P professionals," he says. Love of the Job

Despite constant insurance hassles, backed up schedules, and negotiating patient and office demands, most practitioners say they can't envision themselves working in any other profession. McClellan says he's experienced his share of stress over the years. "You bet," he says. "Many times, but never to the point where I would walk away from the profession." Snell has been in O&P so long he calls himself a dinosaur. He says he has no plans to fully retire. "I love what I do," he says. "Today's technology provides me the opportunity to fit some of the most exciting prosthetic devices I've ever seen. Where else can I go into a patient room and in 30 minutes help change a life?" Betta Ferrendelli can be contacted at betta@opedge.com .

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