SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y
PHYSICIAN WELLNESS VS. BURNOUT New Programs and Resources: CMA, MIEC, TPMG, Marin MDs and Substance Abuse Burnout as an Ethical Issue 20 Years of RENEW A Goodbye Too Soon to a Medical Student
Volume 92, Number 3 | May / June 2019
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IN THIS ISSUE
May/June 2019 Volume 92, Number 3
PHYSICIAN WELLNESS VS BURNOUT FEATURE ARTICLES
MONTHLY COLUMNS
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Membership Matters
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President’s Message: Physician Wellness: Moving Beyond the Bad News Kimberly L. Newell Green, MD
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Stop Blaming the Victims! Irina deFischer, MD
Helping Caregivers Thrive: Cultivating a Culture of Physician Wellness at TPMG San Francisco Jessica Mahoney, MD
11 Marin Community Clinics Burnout Prevention: Using a Trauma Informed Care Approach Mitesh Popat, MD, MPH, Jose Chibras, MD and Elizabeth Horevitz, PhD, LCSW 13 Physician Substance Abuse in California Greg Skipper, MD 15 CMA’s New Collaborative Effort to Promote Physician Wellness
16 Have You Heard? There are Four Steps to Renewing Your Energy, Health and Life Linda Hawes Clever, MD, MACP 19 Lessons in Burnout from a Dying Finn William Andereck, MD, FACP
22 The Mosaic: A Farewell to a Fellow Future Physician Shakkaura Kemet, MPH
32 Community News: Kaiser Permanente Maria Ansari, MD 32 Upcoming Events
OF INTEREST 26 CMA Candidate’s Statement: Health Policy as a Passion Lawrence Cheung, MD
27 Evidence-Based Health Policy in Action: The SFMMS Delegation to the CMA and AMA Michael Schrader, MD and Steve Heilig, MPH 29 Welcome New SFMMS/ CMA Members 32 Advertiser Index
23 Doctors Face a Dilemma When Seeking Mental Health Assistance for Themselves Ellen Goldbaum
24 Medical Errors May Stem More from Physician Burnout Than Unsafe Health Care Settings Tracie White 25 MIEC’s Approach to Physician Wellness Michael D. Anderson, CPHRM
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MARIN MEDICAL SOCIETY
Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org
MEMBERSHIP MATTERS Record Attendance at CMA’s 45th Annual Legislative Advocacy Day With record attendance, more than 600 physicians, residents, medical students and stakeholders, including 30 SFMMS members, gathered in Sacramento on April 24 to bring the voice of medicine to legislators for the 45th annual California Medical Association (CMA) Legislative Advocacy Day. Wearing white coats, physicians converged on the Capitol to educate legislators about critical public health issues, including the dangers of sugar-sweetened beverages and creating standards for vaccine medical exemptions. Attendees also heard from keynote speaker, California Governor Gavin Newsom, who told the packed room about his strong commitment to increasing access to care for all Californians. “I want to be known as the health care governor,” Gov. Newsom said. He gave special thanks in his remarks to SFMMS for our partnership when he was Mayor of San Francisco.
SFMMS delegation vice chair Michael Schrader, MD.
Michael Schrader, MD; recent UCSF graduate Dr. Rachel Ekaireb; and delegation chair Lawrence Cheung, MD. Courtesy of CMA
New Law Requires Regulator to Review Physician Complaints of Unfair Payment Patterns Effective July 1, 2019, the Department of Managed Health Care (DMHC) will be required to annually review complaints filed by providers who believe a plan is engaging in an unfair payment pattern. If the complaint data indicates a possible unfair pattern, DMHC may conduct an audit or open an enforcement action. The effectiveness of this new law depends on physicians and their office staff. Practices are urged to closely monitor their accounts receivables to ensure that they have been paid properly and to report any violations to DMHC through its provider complaint portal or by calling the Help Center at (888) 466-2219. SFMMS/CMA members have access to practice management experts for free one-on-one help with contracting, billing and payment problems. Need assistance? Contact CMA's reimbursement helpline at (888) 401-5911 or economicservices@cmadocs.org.
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Interactive Volunteer Physician Registry Available from MBC A new user-friendly Volunteer Physician Registry is available on the Medical Board of California’s website, making it easier for California-licensed physicians to provide voluntary services in their community. Additionally, the upgraded registry will let clinics in need of volunteers search the database of volunteer physicians using screening criteria such as a physician’s area of medical practice, languages spoken, and the location where the physician wants to volunteer. To register for the Volunteer Physician Registry, visit www.mbc.ca.gov/VPR.
Applications for First Round of CalHealthCares Student Loan Repayment Program Show Overwhelming Provider Desire to Serve Medi-Cal Beneficiaries
The first round of applications for the new CalHealthCares statewide loan repayment program attracted more than 1,200 applications from physicians and dentists who agreed to see more of California’s 13 million Medi-Cal patients in exchange for repayment of their student loans. In all, requests totaled more than $300 million, reflecting tremendous interest in the five-year program, which launched this year. Individual awardees are eligible to receive as much as $300,000 to repay educational debt incurred in pursuit of a medical or dental degree. The program was made possible by Proposition 56, the 2016 tobacco tax measure that provided a one-time allocation of $220 million for state loan repayment for providers who treat low-income patients. That money will be awarded over the next five years. Gov. Gavin Newsom’s revised 2019-20 budget proposes an additional $120 million for loan repayments. For more information, please visit www.CalHealthCares.org.
Pain Management Training for Primary Care Providers Offered by UC Davis
Pain is the most common reason a patient seeks health care, yet it is not widely taught to clinicians. The lack of appropriate pain education has left primary care providers on the front line of healthcare at a substantial disadvantage when managing patients with complex chronic pain. The UC Davis Center for Advancing Pain Relief offers two programs to help close the knowledge gap. These 10-month programs will start in September 2019 and are open to all health care providers and clinics. View information about the Train the Trainer (T3): Primary Care Pain Management Fellowship at http://bit.ly/2Vwuf2l, and view information about the ECHO® Pain Management Telementoring program at http://bit.ly/2HDD45l.
CMA Annual Report Available
Serving more than 44,000 members, the CMA remains committed to its time-honored mission statement: to promote the science and art of medicine, protection of public health, and the betterment of the medical profession. Thanks to the support and dedication of its members, CMA had another high-achieving year of milestones and accomplishments in support of the practice of medicine, as well as providing timely, affordable and quality health care for all Californians. Download the 2018 CMA Annual Report at http://bit.ly/2WORUwz. WWW.SFMMS.ORG
May/June 2019 Volume 92, Number 3
CMA’s Model Medical Staff Bylaws Updated The CMA has released its 2019 Model Medical Staff Bylaws. These bylaws are the definitive guide for medical staffs, providing details on professional and legal structures to support effective medical staff operations and self-governance. The model bylaws are fully annotated to provide background information on critical provisions, including explanations of relevant state and federal laws, hospital accreditation standards, and other explanatory information. The Model Medical Staff Bylaws are available free to any medical staff with an active membership in CMA’s Organized Medical Staff Section (OMSS). If your medical staff is not already an OMSS member, join today at https://www.cmadocs.org/sections/ organized-medical-staff. The model bylaws are also available to non-OMSS members for a fee through CMA's online store at http://bit.ly/2QboGFn. Contact: CMA-OMSS, (800) 786-4262 or medstaffhelp@cmadocs.org.
SFMMS Members Enjoy 15% Discount at California Academy of Sciences
Did you know that SFMMS members enjoy a 15%% discount on tickets to the California Academy of Sciences? Based in San Francisco’s Golden Gate Park, it is home to a world-class aquarium, planetarium, and natural history museum—all under one living roof. Use code ‘sfmms’ to save 15% on tickets at www.calacademy.org/eticket2.
Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Kimberly L. Newell Green, MD President-Elect Brian Grady, MD Secretary Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President John Maa, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP
Opportunity to Serve on SFMMS Physician Wellness Committee
SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA
SFMMS will be re-starting its Physician Wellness Committee, under the leadership of Jessica Mahoney, MD, Chief of Physician Health and Wellness at Kaiser San Francisco (see her article featured in this issue). The Committee will have a kick-off meeting on June 19 at 6:00pm. If you are interested in participating on the Committee, please contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.
Associate Executive Director, Public Health and Education Steve Heilig, MPH
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Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Ian Knox 2019 SFMMS BOARD OF DIRECTORS Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen N. Kumar, MD Michael K. Kwok, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD William T. Prey, MD Justin P. Quock, M Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD
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PRESIDENT’S MESSAGE Kimberly L. Newell Green, MD
PHYSICIAN WELLNESS: MOVING BEYOND THE BAD NEWS This complex problem cannot be solved by a single physician leader or by a single organization. I am so grateful to now be working with a broad community of physician leaders, healthcare system leaders, CMA and MIEC leaders. The news is daunting and even tragic. Depending on the study, more than 50% of physicians are burned out, 39% suffer from some degree of depression, and about 400 physicians commit suicide each year, a rate that is double that of the general population. Hippocrates once said: “Dourness is repulsive to both the healthy and the sick.” And so I won’t get stuck in the bad news. Rather I am excited to plan together a smart and effective approach to the wellness of our physicians, and thereby our patients and our health systems. I have a particular interest in this work because 5 or 6 years ago I was asked to lead Kaiser Permanente San Francisco’s efforts in physician wellness. When I took the leadership role, I knew nothing about this field. So I dove into the literature and talked to experts to get an understanding of the science of wellness and satisfaction, both generally in workplaces and in physicians in particular, to begin to develop an evidence-based strategy for supporting wellness. In my view physician wellness has many prongs: It is an individual journey as we all align our work in our varied settings with our life’s mission and purpose, and we take the time to fortify our body and our mind with self-care techniques. It is a community journey, as we all strive to make meaningful connections with our colleagues around the uniquely challenging work that we do. It is an organizational journey as we work to understand the components of a sustainable workload and develop systems to support that, in the face of dramatic changes and challenges in the way that medicine is practiced. It is an analytic journey, as we use rigorous techniques to assess the needs of our physicians and our systems, and develop means to measure the success of our solutions so we can grow what works and change what doesn’t. At the time I started my role, Physician Wellness was a program that focused primarily on organizing events to help build our physician community, to connect increasingly disconnected physicians – such as those who used to have lunch in a shared space but now spent lunch times charting on the computer at their desk. This is still vital work. But there is so much more to wellness than events. After a great deal of advocacy, we obtained support to expand the program at Kaiser Permanente to include all of the other key drivers in physician wellness and burnout prevention and treatment. The work at KP has been taken over by a passionate and experienced physician leader, Dr. Jessica Mahoney, who writes of their current strategies. WWW.SFMMS.ORG
Dr. Mahoney and the other authors in this issue give us an overview of physician wellness; review some of the evidence about effective strategies to address this issue; and highlight some local programs and efforts to stem the tide of burnout and build resiliency in our physician community. This complex problem cannot be solved by a single physician leader or by a single organization, and so I am so grateful to now be working with a broad community of physician leaders, healthcare system leaders, CMA and MIEC leaders, who know that it is vital that we fortify our physician workforce so that we can do what we all want to do: take excellent care of our patients without draining ourselves of our own health, our vital energy. As advocates for the wellness and satisfaction of all physicians in San Francisco and Marin, SFMMS is very excited to partner with these groups and with individual physicians throughout the two counties to help promote physician wellness. To this end, we hosted two wonderful dinners this spring. We convened leaders in the San Francisco and Marin medical community to hear about their programs, their needs, and to begin discussion about the ways that we can work together to solve this thorny problem and help our patients, physicians and staff, and institutions thrive. We have started a Physician Wellness Committee to help guide our work, and would be excited for any member physician to join us on that committee. I began, and will end, with Hippocrates. He wisely noted that “If someone wishes for good health, one must first ask oneself if one is ready to do away with the reasons for his illness. Only then is it possible to help him.” As leaders in healthcare, we need to look seriously at the reasons for distress in our physician and decide to do away with them. This will not be easy or without effects on our business models, our staffing models, our technology solutions, our revenue streams. But it is the only way to heal our physicians and our health system.
Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at UCSF. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team. A graduate of Princeton University, she completed a Fulbright Fellowship in India and produced a documentary film about cross-cultural healthcare at the Harvard School of Public Health.
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Physician Wellness vs Burnout
STOP BLAMING THE VICTIMS! Irina deFischer, MD It seems everywhere you look there is an article about physician burnout. We hear about alarming rates of depression and suicide, as well as many leaving the profession, either through career change or early retirement. My husband and I both retired just over a year ago, and immediately noticed we were sleeping better and generally felt happier and more relaxed. Many of our colleagues just carry on, despite feeling exhausted, overwhelmed, cynical and afraid. They have apps on their phones counting down days to retirement. They don’t seek help because they feel they should just “suck it up,” or fear the stigma of being labeled with a mental illness. There is a proliferation of programs claiming to stop burnout – they often recommend mindfulness, regular exercise, keeping a gratitude journal in order to find joy and meaning in medicine again. These are good suggestions for anyone, but where to find the time? There aren’t enough hours in the day to get through our work as it is. We are often left feeling that we’re not working hard enough, we aren’t resilient or efficient enough, and we certainly don’t spend enough time with our loved ones. Yet we are among the hardest working, most idealistic, people there are! We didn’t get into med school by being slackers. Residency is not for wimps. Why then are we made to feel like failures when we experience burnout? ZDoggMD (the UCSF-trained physician with a big media presence) recently did a piece entitled, “Stop Calling it Burnout! It’s Not Burnout, it’s Moral injury,” in which he compares today’s physicians to soldiers returning from war with PTSD. He says it is the broken health care system that is destroying us. Whether it is the EMR with its checkboxes and pulldown menus, the “meaningful use” requirements, the countless mandates coming from wellintentioned but burdensome legislation and regulations, the time constraints and metrics imposed upon us by our employers or payors, the never-ending stream of messages, e-mails, lab results, prescription refill requests in our inboxes, or the hoops we have to jump through to get paid or to obtain “preauthorization” for treatments and medications for our patients, we find ourselves spending much more time staring at the computer screen and typing rather than interacting with patients face to face. That interaction is what brings joy and meaning into our professional lives! I’ve been volunteering at our local free clinic for over 20 years, and have noticed a marked change since they introduced the EMR a few months ago. Not only are we missing the information in the paper charts which are no longer provided, but since we’ll all part time volunteers unfamiliar with this 6
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product we struggle to find the most basic patient information and still have to complete paper lab and x-ray requests. The EMR has been compared to a glorified cash register, great for billing but cumbersome for patient care. So, what is a physician to do? Some turn to administrative duties full or part time to escape from full time clinical practices. Many work 3 or 4 days a week in order to better balance home and work life. The primary care colleagues who seem happiest are those who have left traditional practice and gone into concierge care, charging an annual fee and limiting the number of patients they care for. An increasing number of family physicians have chosen to break their ties with insurance companies altogether by adopting the Direct Primary Care model, charging patients a monthly prepaid fee for all services provided in their offices. (This is very similar to the model pioneered by Dr. Sidney Garfield in 1933 to provide care to the workers building the aqueduct to bring water from the Colorado river to Los Angeles. He charged a nickel per worker per day. He later brought this model to the Kaiser shipyards in Richmond, and together with Henry J Kaiser founded the first HMO in the country, Kaiser Permanente, in 1945.) The concierge models are useful only for primary care physicians whose patients are well enough off financially to be able to afford them, and tend to limit panel sizes, exacerbating physician shortages. Some maintain that we would be better off in a single payer system. Whatever we do, we must not suffer in silence. We are not alone, we are not at fault, and, together, we can work towards positive change. Irina deFischer is a family physician who practiced for over 30 years in Marin and Southern Sonoma counties, most recently at Kaiser Permanente in Petaluma. She is a past president of the Marin Medical Society and serves on the editorial board of the SFMMS Journal. Favorite post retirement activity is being Shane’s Grammy!
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Physician Wellness vs Burnout
HELPING CAREGIVERS THRIVE: Cultivating a Culture of Physician Wellness at TPMG San Francisco Jessica Mahoney, MD Physician health and wellness cultivates the soil and plants the seeds of wellbeing to help individual physicians g row m o re h u m a n e a n d rewarding medical practices. “Well” physicians are more effective healers, colleagues and leaders. They provide higher quality and more optimal care experiences and are key to the ongoing success of healthcare. Our TPMG SF physician wellness program aims to optimize individual physician health and wellness, build community and collegiality, refine organizational systems and develop programs to support the sustainable and healthy practice of medicine. A “culture of wellness” for both caregivers and patients promotes exceptional and compassionate care experiences for all. Physicians need to care for themselves so they can continue to effectively meet the enormous responsibility of bearing witness to illness and caring for others in a way that preserves humanity and provides healing through compassion. Physician careers are long and demanding both physically and emotionally. Like high performance athletes, physicians need tools to care for themselves and to optimize and sustain their performance over time. Physician workload, systems issues and lack of community and connection have added to this responsibility and contributed further to physician burnout and associated rising healthcare costs and quality issues. Although TPMG has identified physician wellness leaders since at least 2003, the seeds of physician wellness programming have grown slowly. In the beginning, we met in a small windowless room, had no budget, and spent hours strategizing how to make a business case to “take care” of those providing the care. Today, in the face of tremendous physician burnout, the business case for physician wellness is clear. Funding to support physician wellness is robust and programs to encourage “Joy and Meaning in Medicine” and “Caring for the Caregiver” have become strategic priorities in health care. Our San Francisco TPMG Physician Health and Wellness team functions through both an executive leadership team and a larger local wellness “committee” that includes thirty-five physician wellness leaders representing almost every department. Wellness leads are trained to be effective advocates of wellness in 8
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their own departments and throughout the larger medical center. Our wellness programming sends a strong and consistent message that physician well-being and sustainable medical practices are valued by leadership and provide a path to ongoing excellence. Physicians, however, do not work in silos; healthy and well teams contribute significantly to the improved wellness of physicians and patients. Even EVS workers can be significantly impacted by vicarious trauma and the emotionally intense work of healthcare. Accordingly, in 2019, we are expanding our efforts to include a focus on the wellness of the entire healthcare team including staff and nurses. Physician wellness reminds physicians of the importance of “practicing what they preach” by encouraging participation in programs that support physical and emotional health. We promote the development of healthier eating opportunities across our hospitals and medical office buildings and we partner with our Director of Culinary Medicine and our Thrive Kitchen on teambuilding and nutrition education. We collaborate with our employee wellness team to provide physicians and staff opportunities to exercise and practice mindfulness side by side. A healthy body, emotional intelligence, and self-awareness are vital for everyone working in increasingly complex team environments where sub-specialization, increased technology, and expanding work requirements are the norm.
“Human knowledge is never contained in one person. It grows from relationships we create between each other and the world, and still it is never complete.”
– Paul Kalanithi, When Breath Becomes Air
Vivek Murthy, the former surgeon general, describes how the epidemic of loneliness correlates with poor health outcomes. He emphasizes that it is foundational for wellbeing to feel connected to family and colleagues in a meaningful way. Physician work has become increasingly lonely due to increasing workload and EMR responsibilities. We know that strong physician communiWWW.SFMMS.ORG
ties increase professional satisfaction, physician engagement, and protect against burnout. To combat physician loneliness, our physician wellness team works to create meaningful connections between colleagues. We host “no agenda” lunches and evening socials for physicians to enjoy in a relaxed informal “physician lounge” type environment. Live music is often provided by fellow physicians. We also organize interdisciplinary gatherings to provide targeted opportunities for physicians to build collegiality and improve communication. Previous gatherings have included the Palliative care, Breast care, Transgender care, Maternal Child Health and HBS/ICU teams. Physician Wellnesssponsored “Book Clubs” have been a powerful tool to strengthen and engage our teams and optimize care experience. Chosen books address shared experiences as health care providers and patients. Recent offerings include In Shock, Being Mortal, When Breath Becomes Air and the Gratitude Diaries. Women physicians suffer particularly high burnout rates. Our popular “Women in Medicine” program creates opportunities for this high-risk group to connect and share the joys and challenges of practicing medicine as a woman. We discuss topics that address shared burdens such as women in leadership, mindful eating, gardening tips, financial planning, de-cluttering your life, caring for aging parents, parenting, menopause, incontinence, and breast cancer prevention. Collaboration with medical center leadership teams whose shared purpose is to support physicians and build healthier more “well” environments has been an effective culture change tool. We have worked with our Green Team to eliminate plastic water bottles and sodas at physician meetings and worked with Department Technology Leads to optimize the integration of technology and the sharing of wellness resources more effectively and broadly. Our partnership with the CME Chief has brought renowned wellness speakers and authors to our medical center and hosts our annual Tahoe Winter Wellness Conference. Together with our Communication Consultants, Employee Assistance Program, Physician Human Resources, Medical Legal, and Department Chiefs, our wellness team has built a program to decrease the stigma around physicians reaching out for personal or professional support. We created an innovative “Physician Resource Guide” to educate our physicians about available resources and strategies. This resource has been shared with
S P O TLIG H T Physician Wellness Retreats and Mindfulness Training “We are never so wise as when we live in this moment.”
– Paul Kalanithi, When Breath Becomes Air
Our SF medical center offers an innovative physician-led workshop available to career MDs every two years. The program was developed by our physician wellness leadership team and has been supported by medical center leadership as a performance tool for three years. More than 240 of our 700 physicians have participated. Thirty physicians from mixed specialties gather in nature at a retreat center for a day. Through facilitated group discussions, we teach practical methods to incorporate varied forms of mindfulness and meditation, focus and presence into physicians’ medical practices. Group sharing around reconnecting with one’s joy and purpose in medicine and discussions of mindfulness research and how it can improve personal health, patient care outcomes and patient and physician satisfaction also occurs. The shared physician experience and leadership support of the program have resulted in a profound culture shift. Nearly all teams are now using mindfulness and gratitude in daily operational huddles and even in the operating room. The response from participating physicians has been overwhelming. Feedback from participating physicians on how the program has impacted their professional satisfaction, personal wellness, and/or performance as a physician includes: “Connecting with colleagues in this unique setting is invaluable and no doubt leads to better workplace culture and collaboration in caring for patients.” “It gives me such happiness to know that my organization values our wellness and gives us some concrete tools on how to do this.” “Experiential learning is really helpful for increasing awareness“ “This helps me to be a better physician – I am healthier in mind, body and spirit after attending these and I will bring this better self back to work!” “Helped me find some coping mechanisms to prevent burnout.” “Increased appreciation of the effort placed by our leadership to improve physician well-being and empower physicians to share experience with the rest of their medical teams.”
physicians across our medical center through New Physician Orientation, Department Technology Lead workshops, Leadership trainings, and Mentorship programming. Department Chiefs are undergoing training on how to identify and support doctors in distress. These efforts have led to a significant increase in utilization of the detailed programs and increased scores on our Physician Opinion survey on Physician Wellness measures. Although our programs are many and our progress toward a healthier physician workforce steady, making meaningful and continued on page 10
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Physician Wellness vs Burnout S P O T L I G HT Leading with a Lens to Wellness: A Physician leadership training program “Leading with a Lens to Wellness” has trained over 45 operational leaders including department chiefs/chairs and medical center leaders over the last 2 years how to make decisions with physician wellness as the guiding principle. This program educates physician leaders about evidence-based strategies to optimize physician engagement and professional satisfaction. Strategies include how to allow for increased physician flexibility, autonomy, and control, how to build community and cultivate collegiality, how to create opportunities for more physician involvement in developing practice efficiencies, and how to expose physicians to opportunities for professional development at every stage of their career. Improving physician evaluations, feedback and coaching, and designing creative opportunities for fully engaging the entire medical team more fully in the work of medicine are also discussed. This program has already led to meaningful and sustainable positive change in the day-to-day experience of our physicians. When operational decisions are discussed, the impact on physician wellness is now included as a decision-making factor. Specific changes shared by leaders include communication practices, approaches to physicians returning from leave, physician feedback, professional development opportunities, and scheduling practices. This program is scalable and has now been replicated at several KP medical centers in Northern California with equally encouraging results. It is currently being incorporated into a TPMG system-wide program to provide department leaders guidance in responding effectively to physician wellness concerns identified on standardized surveys measuring physician engagement and well-being.
Physician Tahoe Winter Wellness Conference
The SF TPMG Physician Tahoe Winter Wellness conference has been ongoing for over 10 years. It started as a grass roots effort by a small group of physicians at Kaiser Permanente in San Francisco who wanted to earn CME near the ski slopes. Through Physician Wellness and CME leadership collaboration, this conference grew to include over 250 physicians from around Northern California and their families (over 700 total attendees in 2018!) This hugely popular weekend includes educational conferences on wellness topics such as sleep, exercise, mindfulness, ergonomics, screen addiction, along with many shared meals and opportunities for yoga, skiing, swimming, and ice skating. We recently began hosting educational documentaries followed by group discussions on topics of shared interest to physicians and families such as screen-time and sugar. Because of its success, the program has recently been taken over by our Regional leadership team and this year included over 350 TPMG physicians from across Northern California.
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sustainable change in the day-to-day lives of physicians requires work beyond lifestyle change and community building. “Operationalizing Wellness” and encouraging “Joy and Meaning” are critical. Accordingly, we developed our “Green Gulch Physician Wellness Retreat” program to focus on incorporating mindfulness, meditation, purpose, and gratitude into both the practice of medicine and one’s life. This popular program builds collegiality, connection and community among physicians from different departments and across multiple facilities (see Spotlight for details). “Leading with a Lens to Wellness” is a leadership training program led by Physician Wellness that to help build both workplace culture and operational systems to better support physician resilience and engagement and prevent burnout (see Spotlight for details). Our “Expanded Mentoring Program” further supports physicians throughout their career at five-year touchpoints. Lunchtime physician panels share the wealth of professional opportunities such as advocacy, community benefits, volunteerism, innovation and leadership opportunities, research, teaching, mentorship, technology development and systems improvement. When we nurture physician health and plant seeds of well -being through wellness programs, our work environments begin to transform into supportive places where physicians can find meaning and joy despite the challenges inherent to medical practice today. Physician wellness has been a personal passion for over 18 years. There is no more important or enjoyable professional purpose than working to improve the wellness of my hardworking colleagues, so they can bring their best selves to this important work now and for years to come.
Dr. Jessica Mahoney is a practicing pediatrician and the Chief of Physician Health and Wellness at The Permanente Medical Group in San Francisco. Since 2003, she has served as a physician health and wellness leader working to improve physician sustainability and satisfaction. Dr. Mahoney is a frequent speaker and facilitator for physician wellness workshops and works at both the local and regional level developing TPMG physician wellness strategies and initiatives. She is the current Chair of the California Medical Association's Subcommittee on Physician Wellness and previously served as the Site Chief of Pediatrics at Mission Bay. Dr. Mahoney is also a certified yoga instructor and will complete her certification as a life coach in September 2019. Her current passion is integrating a coaching mindset and mindfulness and yoga into all areas of her work to improve the health and life experience of her patients, their families, and her colleagues. Dr. Mahoney graduated from the UCSF in 1997, and Dartmouth College in 1991.
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MARIN COMMUNITY CLINICS BURNOUT PREVENTION Using a Trauma Informed Care Approach Mitesh Popat MD, MPH, Jose Chibras, MD and Elizabeth Horovitz, PhD A middle-age man comes to our Larkspur clinic for a routine diabetes follow up and his provider notes that the patient’s most recent Hgb A1c has jumped 3 points. Upon further inquiry about medication adherence, his provider learns that the patient has stopped picking up the prescribed insulin since becoming homeless again and lacking a way to refrigerate the medication. A young woman comes into our San Rafael Campus clinic for her first intake with the Comprehensive Prenatal Services Program (CPSP) worker after missing multiple prenatal visits. When asked what the barriers are to her making her appointments, she tearfully discloses that her pregnancy is a result of sexual assault. She reports that she has been having suicidal thoughts. A young school-aged boy comes to our Novato clinic with his aunt to get vaccines for school entry, and the pediatrician asks about his family and living situation. His aunt reveals that the child recently fled from El Salvador to come live with her after witnessing his father and his cousin be brutally murdered outside his home just a few months prior. These patient stories are tragic, but unfortunately, they are not unique for our medical staff. As Marin County’s largest safety net healthcare provider, Marin Community Clinics serves over 37,000 patients annually, and is committed to providing services to all individuals regardless of their ability to pay and without regard to ethnicity, race, language, age, gender, sexual orientation, or immigration status. In 2017, the majority (96.1%) of our 34,021 patients earned 200% or less of Federal Poverty Guidelines, and nearly a quarter of our patients are uninsured. Providing healthcare for this population has its constraints, but our staff members work incredibly hard to ensure that every patient who walks through our doors receives high quality, costeffective, culturally sensitive, patient-centered health care. This work requires not only the recognition of patients’ trauma, but also the awareness that many of our providers and staff have themselves experienced trauma in their own lives. Collectively, we have staff who have experienced struggles with depression, loss of loved ones to violent crime, abuse in their WWW.SFMMS.ORG
childhoods, intimate partner violence, and more. We know from the original Kaiser-CDC Adverse Childhood Experiences (ACES) study that these experiences are incredibly common.1 We at Marin Community Clinics are proud that our staff reflects the community we serve, and believe our own personal journeys are what allow us to build empathetic relationships with our patients and deep connections with our community. However, as leaders of the organization, we must also recognize that caring for vulnerable and traumatized patients every day can be triggering to our own staff and lead to secondary trauma, compassion fatigue and ultimately increase the risk of burnout. Numerous studies have noted the high rates of burnout in the medical field (as high as 54% of physicians in one 2014 study2) and specifically point to stressors like high-patient needs, lack of resources, onerous documentation requirements, etc., that many of us take as a given when working in the safety net setting . However, there are also protective factors against burnout especially in the primary care setting3, like the perceived ability of one’s clinic to be able to address a patient’s social and behavioral health needs4. In order to enhance our own protective factors, we at MCC have joined a select group of healthcare safety net organizations in the Resilient Beginnings Collaborative. This two year initiative is funded by the Center for Care Innovations5 in partnership with Genentech Charitable Giving with the goal of transforming our clinic from a traumatized organization (one that is fragmented, has an authoritarian leadership style and is reactive to trauma) to a trauma-healing organization (one that is reflective, collaborative, and is growth and prevention oriented). To achieve this, there are 6 principles of trauma-informed systems and 6 competencies for leadership6. To address principles and competencies, we have chosen to focus on the three domains of individual practices, departmental procedures and organizational policies simultaneously. To start this crucial work, we recently underwent an allstaff, trauma-informed care training facilitated by Trauma continued on page 12 MAY/JUNE 2019
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Physician Wellness vs Burnout Mitesh Popat MD, MPH, is CEO, Marin Community Clinics. Dr. Popat is a Board Certified Physician in Family Medicine, obtained his MD and MPH from Tufts University and completed his residency at Stanford/O’Connor Hospital. He recently completed a two-year healthcare leadership fellowship with the California Healthcare Foundation and UCSF.
Transformed7 for all 500 employees from front office and billing to medical assistants and providers. This training equipped our staff with a shared language around trauma, promoted selfreflection, and included individual strategies on how to selfregulate around potentially traumatizing situations. In order to build empathy in the moment, we are taught to ask “what could have happened to this person?” rather than “what is wrong with this person?” when encountered with a so-called “difficult” patient. We have also invested in follow-up trainings with our executive team to identify concrete steps each director can take to develop a relational leadership style and build a supportive workplace community through their own departmental policies and procedures. Furthermore, we will be looking externally for more resources to prevent provider burnout like those through the CMA, and internally to identify project champions throughout our organization to lead this movement forward. By taking care of ourselves and each other, we can take better care of our patients. This work is a reflective and ongoing process that involves intervention at the individual and organization-wide level. We at Marin Community Clinics remain strongly committed to addressing the problem of provider and staff burnout, and for us that is both a responsibility and a privilege.
Jose Chibras, MD, is CMO, Marin Community Clinics, Dr. Chibras specialized in Internal Medicine and primary care, obtained his MD from Michigan State University, and completed his residency at University of Iowa and Michigan State. He completed his fellowship in Primary Care Psychiatry in 2016. Elizabeth Horevitz, PhD, LCSW, is Director of Behavioral Health. Dr. Horevitz oversees the behavioral health department at Marin Community Clinics. She obtained her PhD and MSW from UC Berkeley and completed her post-doctoral fellowship in Clinical Services Research at UCSF.
References 1. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html 2. https://www.mayoclinicproceedings.org/article/S00256196(15)00716-8/fulltext 3. http://www.clinicians.org/images/upload/Stress_and_Provider_Retention.pdf 4. https://www.jabfm.org/content/jabfp/32/1/69.full.pdf 5. https://www.careinnovations.org/programs/resilience/ 6. http://traumatransformed.org/wp-content/ uploads/8.5x11-HANDOUT_-Principles-and-LeadershipCompetencies-of-Trauma-Informed-System.pdf 7. https://traumatransformed.org/
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PHYSICIAN SUBSTANCE ABUSE IN CALIFORNIA California was one of the first states to develop a program for early detection and treatment of physicians with substance abuse problems, but the program was closed in 2007. Now, California is one of the only states lacking such a program. The result has been catastrophic for many physicians and their patients. Substance use disorders (SUDs) among physicians are an endemic problem. A recent survey sent to 27,276 physicians reported an overall prevalence of SUDs of 15.3%,1 consistent with previous studies. This fact cannot be ignored and a competent plan to address the problem is essential for patient safety. A more effective approach, designed for early detection, is needed. Physicians use alcohol and other drugs for the same reasons as non-physicians attempting to deal with stress, personal trauma, and chronic pain, often as self-medication. Those susceptible to SUDs slowly progress over time. As the illness progresses it can cause impairment that can lead to patient harm. Early detection and competent management should be the goal, to protect patients and their physicians. The AMA, the Federation of State Medical Boards and the Joint Commission all agree there should be an effective plan for early detection. Stigma regarding mental disorders in general, and substance use disorders in particular, and harsh punishment by Medical Boards and criminal authorities leads to delayed detection, isolation of those affected and is a significant barrier to early detection and treatment. Lack of training and understanding how to approach these disorders further complicate the issue. Fortunately, a system of care evolved nationally since the 1970’s to better address the problem. Almost all state medical boards now endorse complementary clinical programs for early detection, referral and monitoring of affected physicians. These programs, generically called Physician Health Programs (PHPs), have been very successful, helping physicians and protecting patients. Unfortunately, California discontinued its program and powerful forces have opposed a new program.
How does an effective PHP function?
The most effective state PHPs exist as non-profit programs, typically staffed by a physician and therapists, under a supervisory board. An understanding exists with the medical board that confers authority to the PHP to officially encourage early identification, intervention, evaluation, treatment and monitoring of affected physicians. To encourage early detection, it is important that referrals to PHPs can be confidential and that physicians who come forward are not punished as long as they cooperate. To assure patient safety it is important that the PHP have stanWWW.SFMMS.ORG
Greg Skipper, MD
dards that require referral to the medical board for potential disciplinary action of any non-compliance that might cause risk to patients. In other words, the effective PHP becomes a clinical arm of the medical board, cooperating with it to educate hospitals and medical groups regarding early signs of substance abuse and provides assistance to help with intervention, referral for appropriate evaluations, effective treatment and then oversees long-term monitoring to assure that every recovering physician remains safe. The bottom line is that Substance Use Disorders are illnesses that can be detected early and treated effectively long-term. The success rates of PHPs are high with no demonstrable risk to patients.2
Are Physician Health Programs really effective?
Physicians struggling with substance abuse are embarrassed, afraid and discouraged. They have often attempted to quit on their own many times. They are afraid of what will happen to their career should their secret become known. They repeatedly attempt to quit or moderate their use. They become extremely discouraged when they are unable to stop. Denial is part of the illness. When symptoms become prominent enough others realize there is a potential problem. Family, colleagues or hospital leadership begin to realize they must act. If there is a well-functioning confidential authorized state PHP it can be contacted for immediate action. Unlike the slow machinery of the administrative law system wielded by the Medical Board that can take years, the PHP can act immediately. It contacts the physician and lets them know there is a concern and the physician must stop work and undergo a clinical evaluation. The evaluation must be extensive and not miss the diagnosis, if present. For best results, specialized evaluation programs are preferred. The best evaluations are conducted by a collaborative team including: internal medicine with blood work (liver function testing and other labs), physical exam, psychiatric evaluation and psychological testing (including neuropsychological screening), addiction medicine assessment (including state of the art drug testing of urine, hair, nails, and/or blood as appropriate) and, most importantly, interviews with family, friends and peers.
Why would a physician cooperate after being contacted by the PHP?
Physicians comply because the PHP is confidential and is compassionate in attempting to help and because a refusal could result in referral to the medical board for disciplinary action. An effective evaluation is conducted over 2-3 days and if a diagnocontinued on page 16 MAY/JUNE 2019
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Physician Wellness vs Burnout sis is made it is clearly explained. The physician then undergoes treatment, including withdrawal management, psychosocial rehabilitation and extensive aftercare planning. Once the physician is ready to return to practice, anywhere from 1 – 3 months or more later, they return with ongoing monitoring for 5 years or more by the PHP. This model has been proven effective and safe and is active in most states.
Why Does California Not Have a PHP?
California previously had a board sponsored PHP called “the Diversion Program.” Audits of the program were performed by a leader of a consumer advocacy group. Faults were found and media attention was elicited. Under pressure the program was cancelled it in 2007. However, no actual patient harm associated with the program was ever detected. It was not a perfect program. There was no medical director, therefore leadership of the program was lacking. The program was run by the medical board rather than being independent. It could have been reorganized and modeled after successful programs in other states but instead it was just cancelled. Attempts to reestablish a program have faltered. Consumer advocacy groups, in particular the Center for Public Interest Law, have relentlessly continued vigorous opposition to the establishment of a new effective program. Their quest to assure that physicians with substance use disorders are punished has ironically been to the detriment of patient safety. Their argument has been that the old program was ineffective and that the medical board should be a disciplinary body and only advocate for patients and not for physicians. They claim that physicians should seek treatment on their own if they need it and the board should not be involved.
What happens to Physicians with Substance Use Disorders in California?
Physicians with SUDs in California are severely punished with no emphasis on rapid intervention, evaluation or treatment. At great cost, for the state and the physicians, the judicial apparatus of the state, utilizing the Attorney General’s Office, is levied against these physicians. To inflame the situation further, the medical board refers substance using physicians to criminal authorities. Accusations are filed to revoke the physician’s medical license. Hospitals are required to report not only action against doctors but even investigations. Many hospitals have all but ignored the Joint Commission requirement to provide safe haven for physicians to receive treatment. Hospital attorneys recommend the least liability in terminating the physician and referring them to the medical board. The medical board proudly boasts it has invested significant resources into exposure and punishment: providing apps that patients can put on their smartphones to alert them if their doctor undergoes discipline and a new law that specifies that doctors on probation for substance related disorders must obtain signed consent from new patients. This will mean that being on probation will end careers in medicine. The Medical Board of California has shown aggressive zeal in punishing physicians and it has set a tone in the state not conducive to early detection. Huge amounts of money are wasted and treatment is delayed for years in the process.
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In this extremely hostile climate, physicians are afraid to seek help. Colleagues, hospitals and families are loath to make referrals. Substance use disorders therefore go unchecked until there is a disaster and patients are harmed. (Board records show slow resolution following complaints of substance use, often up to 3 years, and patient harm occurring during that time. Additionally, there are numerous cases where physicians are fired from jobs because of suspected substance abuse without referral, later harming patients because of delayed reporting.) In response to these cases, the consumer groups lobby for harsher punishment, only make the situation worse. A state law was finally passed by the California legislature in 2016 mandating that the Medical Board create a new PHP. However, the new program has been bogged down by wrangling about how it will operate, whether there will be a confidential component, and how punitive and restrictive it will be. There appears to be little sign that an effective program will emerge. It is a sad situation that one of the most progressive states has one of the worst systems of early detection and care for physicians with SUDs. Patients are being harmed. The medical board should understand that helping physicians and improving patient safety are complementary and not mutually exclusive. A competent effective PHP is desperately needed and should be established. Ill-founded opposition by consumer groups should be ignored.3 Greg Skipper, MD is a Distinguished Fellow of the American Society of Addiction Medicine. Dr. Skipper has devoted his 38-year career to assisting professionals in crisis, working with Regulatory Boards, the Federation of State Medical Boards, the Federation of State Physician Health Programs and other Professional Health Programs in the United States and abroad. He has published extensively regarding issues related to professional impairment. Dr. Skipper is the Medical Director of the Center for Professional Recovery (formerly Promises Professionals Program) in Santa Monica CA, where he has evaluated and treated over 800 health professionals since 2011. Previously he was Medical Director of the Alabama Physician Health Program for 12 years. Dr. Skipper was the innovator of ethylglucuronide (EtG) testing and is an expert in drug testing and alcohol markers. He was a member of the National Advisory Council for the Substance Abuse and Mental Health Services Administration (SAMHSA) from 2002 – 2008. Dr. Skipper is a popular speaker regarding Drug Testing, How Medical Regulatory Boards function, How Attorneys Think Differently Than Doctors, Medical Errors and other similar topics.
References 1. Oreskovich MR, et al. The Prevalence of Substance Use Disorders in American Physicians. Am J of Add. 24:30-38, 2015 2. McLellan T, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038 3. Collier R. Healthier Doctors, Healthier Patients. CMAJ. 2012 Nov 20; 184(17): E895-E896 WWW.SFMMS.ORG
CMA's New Collaborative Effort
TO PROMOTE PHYSICIAN WELLNESS The California Medical Association announces a new statewide collaborative effort with leading ex p e r t s o n p hys i c i a n wellness from the Stanford Medicine WellMD Center: Tait Shanafelt , M.D., center director, chief wellness officer and prof e s s o r o f h e m a t o l o g y, and Mickey Trockel, M.D., project co-leader and clinical associate professor of psychiatry and behavioral sciences. This new program will promote physician wellness across California and will be the most comprehensive state level effort in the country. Dr. Shanafelt and Dr. Trockel are nationally recognized leaders on physician wellness who bring academic expertise, as well as hands-on experience building successful organizational initiatives to improve physician fulfillment and wellbeing. The program will utilize a population health framework to address systemic contributors to physician burnout, along with providing tailored support for physicians at increased risk or experiencing specific challenges. In addition to creating tools to support changes that the health care system can make to increase physician wellbeing, the program will assist those already expressing signs of physician burnout. The program will also include offerings that range from local physician groups (to help physicians reconnect with their peers and to meaning in their work) to tools that help physicians calibrate their wellbeing, while also linking those physicians who have markers of burnout to additional resources. Training will be made available to empower physician leaders to build practice environments that support professional fulfillment. The program will also include an annual comprehensive, longitudinal assessment of the experiences of California physicians to identify new opportunities and measure progress. CMA is extremely proud to work with Dr. Shanafelt and his team to better combat physician burnout, which occurs from medical school through active practice,” said CMA President David H. Aizuss, M.D. “This program’s scope, innovative approach and resources are unmatched in the nation, and it will substantially improve physician wellness while supporting patient access to quality care.” “This collaboration will implement a comprehensive approach to promote the wellness of California’s physicians using a population health framework” said Shanafelt. “Given the strong links between physician distress and the care they provide patients, WWW.SFMMS.ORG
we believe improving physician wellness benefits not only physicians, but the patients and communities they serve.” “This project aims to promote wellness for all physicians, deliver specific interventions to those most at risk for burnout, and provide timely interventions to those already in distress,” said Trockel. “Along with broad focus on promoting wellbeing, this tiered approach also sets the ambitious goal of preventing physician suicide in California.” Burnout, an occupational syndrome marked by exhaustion, cynicism and loss of purpose in work, has been increasing among physicians. Over half of U.S. physicians report symptoms of burnout. The National Taskforce for Humanity in Healthcare estimated that physician burnout is costing the nation’s hospitals and health systems $1.7 billion per year. When burnout-related turnover among all U.S. physicians is considered, the costs could be as high as $17 billion. “The well-being of the nation’s physicians is a critical factor in maintaining access to care and the quality of our health care system,” said wellness program CEO Kathleen Creason. “The program will help physicians conquer these issues, so they can do what they do best – care for patients.” National studies led by Dr. Shanafelt indicate that burnout is more common among physicians than U.S. workers in other fields. Physician burnout has also been associated with risk for suicide among physicians. Burnout can erode the quality of patient care and decrease patient satisfaction. It can also limit patient access to care, as physicians experiencing burnout often cope by reducing the number of patients they see, reducing their clinical time or leaving the profession entirely. For updates on the program, see: https://www.cmadocs.org/ wellness
SFMMS WELLNESS COMMITTEE Stay tuned for more on this CMA/Stanford program. More locally, SFMMS will be re-starting its own Physician Wellness Committee, under the leadership of Jessica Mahoney, MD, Chief of Physician Health and Wellness at Kaiser San Francisco, whose article is featured in this issue. Please do get in touch if you are interested in participating in this reinvigorated effort. Contact Erin Henke at ehenke@sfmms.org. MAY/JUNE 2019
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HAVE YOU HEARD?
There are Four Steps to RENEWING Your Energy, Health and Life Linda Hawes Clever, MD, MACP Twenty one years ago, back in the day before Electronic Health Records, we started RENEW, then a special project of now-California Pacific Medical Center’s Institute for Health and Healing. The goal was to start a movement, a movement aimed at helping physicians reclaim vitality and purpose—even joy!—in both work and life. The idea was to build community and strengthen institutions and organizations. We wanted ourselves and our profession to flourish. RENEW’s ambitions stretch far beyond preventing and treating “burn-out”, which the Maslach father-daughter team strictly defined as specifically work-related. The purpose also goes far beyond achieving “work-life balance”, since balance is so difficult to attain and maintain. You know how long it take a baby to toddle en route to walking and how long it takes an elder to advance to tottering after a stroke. Furthermore, RENEW never works with “providers.” No. Physicians take an oath, we take a vow. That’s what “profess’’ means. We are professionals, far far more than providers. RENEW works with professionals. That includes nurses, who quickly joined the RENEW movement, and serve on the Board and participate in programs. From the beginning, we’ve explored and reaffirmed personal values in order to tap deep reservoirs of meaning, enthusiasm and talent so we all can move ahead. Interestingly, every single group we’ve talked with has listed honesty and/or integrity as values. No other value has that unanimous endorsement, although reliability, hard work, learning, and kindness are common—family and friends less so. Over time, we developed a curriculum based on adult learning theory and change theory. Our workshops, seminars, consultations, keynotes and collegial Conversation Groups© touched other health professionals as well as students, faculty, clergy, volunteers, staff, and leaders in hospitals, clinics, practices, and universities. Over two-plus decades, RENEW pressed forward creating the world’s longest bumper sticker, as it were, “It isn’t selfish to take care of yourself. It’s self-preservation so you can do what you need to do and what you want to do.” We formulated principles. We designed effective methods and rafts of materials (see and take the RENEW-o-Meter at www.renewnow.org) and touched tens of thousands of lives in meetings around the United States. We chose always to work with groups, since they provide warm and good company, generate ideas fast, and show people that they are not alone. Thanks to a residency at Mesa Refuge, I was able to write a book, The Fatigue Prescription: Four Steps to Renewing Your Energy, Health and Life that readers still buy (thankfully). The prescription? First comes Awareness, then Reflection, then Conversation, then Plan and Act. The process is neither a straight nor a fast shot, yet it is effective. What are the results? We have evaluated outcomes 3-6 months and even years after programs and receive responses such as, “I started leaving the office at 6:30 PM. I started going to grand
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Principles of RENEW o
Renewing begins by affirming values. Values define meaning in life and motivate action.
oGaps between values and behavior are sources of
depletion and signals that it’s time to renew.
oWhen people renew, they enhance the vitality of
their work, families, friendships and communities.
oWhen people weave renewing into their daily
lives, they gain resilience and add to their capacity to change and grow.
oRenewing is best done in good company. Conversations,
sharing stories, encouraging and validating one another are powerful catalyst for positive change and growth.
oRenewing allows people to discover that they
already possess many of the answers and much of the wisdom they seek.
oRenewing also allows people to discover that while
they can’t always control their circumstances, they can choose their attitudes and responses.
oRenewing gives people greater access to the
sizeable reservoirs of talent, courage and creativity that are within them.
oOne’s sense of humor is a sensitive barometer. The
more people are able to see humor in life and to laugh at themselves, the less they need to renew. And vice versa.
oRest, reflection, risk-taking, learning and exercise
are essential ingredients of renewing.
oSpeaking, writing and artistic expression clarify
values and make it easier to be true to them.
oRenewing would be hard work if it weren’t so enjoyable. rounds regularly. I started a men’s book club. Thanks for the kick in the butt.” Another physician said, ”It’s made me more empathetic toward my patients. I realize I need to spend a little more time and listen, just like I want to be listened to.” People begin to make life and work decisions based on the values and feel more capable, energetic and optimistic. Devoted, busy people who face relentless change and challenge can rise up. A nurse said, “Hey, this stuff works!” A junior faculty member had the ah-ha, “I can always get another job but if I screwed up my children, I’d torture myself forever.” National professional organizations accepted the concept that clinicians need to be healthy in order for their patients and families to be healthy. After a series of plenary sessions and workshops, the American College of Physicians added to its Core Values and Mission statements, “ We maintain healthy personal and professional lives to most effectively serve our patients and “[We} support healthy lives for physicians.” WWW.SFMMS.ORG
It was lonely, back when not everyone saw that our noble commitments could be overwhelmed by turbulence and competing, clanging imperatives. John W. Gardner, PhD, statesman, scholar, mentor and tough-minded optimist, understood the complexities and unhappy consequences of unrelenting strain, and inspired and helped start RENEW. We thought that something must and could be done. Dr. Rachel Naomi Remen thought so, too, and had started Finding Meaning in Medicine®, now expanded into the Remen Institute for the Study of Health and Illness based at Wayne State University. (Naomi once told me, “Finding Meaning in Medicine is about finding meaning in medicine. RENEW is about finding meaning in life.”) A few sainted deans, department chairs, directors of nursing and nursing supervisors along with a strong Board and Panel of Advisors and generous donors recognized the dangers to clinicians and patients and supported our growth. To celebrate our decades, we held a a 20th anniversary conference in November 2018, and invited pacesetting students, clinicians, educators, leaders and scholars. A Fireside Chat reviewed RENEW’s history, philosophy and stories. Sessions, interspersed with art and a ukulele-playing neurosurgical ICU nurse, focused on RENEW’s pillars: “Assuring a Strong Start and Finish: Renewing Innovations in Education”, “Lessons from the Field: Building Renewing Inroads into Organizations”; and “Integrating Complimentary Care into Health Care: News Flashes.” We held Conversations Groups© on Barriers and Boosters to Change and opined on “What’s Next for You and RENEW?”
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Looking to the future, we see continued need and increasing welcome in health care and the not-for-profit worlds. We also see hunger among those who care for elders to be better than busy and to be fulfilled, just like other care-givers. Elders themselves agree, so we are starting Conversation Group© in their residences and for staff members therein. Not everyone has joined the race to the top, yet increasing and meaningful involvement of health care systems and health centers is heartening. The National Academy of Medicine’s Action Collaborative for Clinician Well-Being and Resilience came out of the starting blocks strong and is demonstrating its ability to be practical and useful. It is encouraging to work with the Collaborative (https:// nam.edu/initiatives/clinician-resilience-and-well-being/). We are getting there. We will keep on keeping on. The idea is for clinicians to have whole healthy lives, too, just as we strive for our patients. We should cross the finish line together.
Linda Hawes Clever, MD is founding President of RENEW, a not-for-profit aimed at keeping devoted people at the top of their game. She is an internist trained at Stanford and UCSF, a member of the National Academy of Medicine, former Associate Dean at the Stanford University School of Medicine, and is the author of The Fatigue Prescription: Four Steps to Renewing Your Energy, Health and Life. She loves her family and friends and likes good walks, good conversation, and good cookies.
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LESSONS IN BURNOUT FROM A DYING FINN William Andereck, MD, FACP Our bioethicist got the call on a Monday afternoon. The ICU had another unrepresented patient who was not doing well and required life or death decisions soon. He was a 6 foot, Nordic appearing gentleman who was well groomed, but he had suffered a pontine hemorrhage and was unresponsive, on a ventilator, and requiring a nasogastric tube. As is often the case, the patient had reached the point that he would require tracheostomy and PEG tube placement if we decided to keep him alive. What was best for him; and, slightly differently, what would he want in this situation? In my years of experience, the default is almost always to “trach and peg”. Social services had been unable to identify a relative or any other individual who could serve as a surrogate. As best we knew, he was just another “John Doe” with a stoke. Meanwhile the medical and nursing team were struggling with what they thought was their obligation to keep Mr. Korhonen1, as we now knew him to be, alive without someone to give them permission to do otherwise. Immediately on receiving the consult our team reinvigorated the search for a surrogate, friend, or relative. Sure enough, two days later we heard from his ex-wife who professed to know him well. No more than three hours later we got a call from another ex-wife who also spoke lovingly of our patient. By the end of the day we heard from a gentleman who claimed to be his best friend and saw him daily. And it began to snowball from there. As we met more and more of his friends, we got the same story, Mr. Korhonen would never want to spend the rest of his life on a respirator. Based on his dismal prognosis and strong evidence of what we perceived to be his wishes, the medical team decided to remove the respirator and provide Mr. Korhonen with comfort care measures only. When the time came to remove the endotracheal tube, there were over 30 people in the room and spilling out into the hall, most of them jabbering in Finnish, but the English we heard were stories regaling the kindness and exploits of what was previously our John Doe. It turns out that Mr. Korhonen was the lynchpin of the Finnish community in San Francisco. He never remarried a third time and now lived alone, but every day he could be found in his newsstand in the Transbay Center. Every Finn arriving in San Francisco knew to go directly to Mr. Korhonen’s newspaper WWW.SFMMS.ORG
stand to get immediately connected to the Finnish diaspora in the Bay Area. He was known and loved in their community. One gentleman told us that “If the Finns had a Mafia, he would be the Don.” We could not help but think of Gaudi, the Barcelona architect, who lay unrecognized in the pauper’s ward for 4 days after being hit by a streetcar. As the stories went on someone started pouring a sweet liquid into the medicine cups that were being passed around. I’m sure it was medicinal. And then, as one, everyone raised their cups in an unintelligible toast while the tube was removed. Tears were shed and hugs were distributed. As expected, Mr. Olsen lingered peacefully for a few days before he died, continually visited by friends who just wanted to say good-by and share a few stories with the nurses. For all of us in attendance, this was a magical moment. One that reaffirms all the reasons we entered the medical profession. Yes, the patient died, but he was not alone, and the medical team did the right thing. What makes clinical medicine so special is when we are able to see beyond the patient with a disease, such as a stroke, to who the patient really is, as a person. My colleague Thomasine Kushner taught me many years ago the difference between the “biology” of a person - their physiologic presence, and the “biography” of a person - what they have done in their life and who they have influenced. Discovering Mr. Korhonen’s biography brought some humanity to an otherwise faceless death. We had all had a long day, but on this one at least, we went home feeling proud to be in health care. We had done right by Mr. Korhonen. Why, you should ask, am I telling such an uplifting and profession-validating story in an issue centered on physician burnout? The reason is that during that magical moment of Mr. Korhonen’s extubation, nurses, therapists, ethicists, and social workers were all present and inspired, but there was no doctor in the room. The order to extubate had been executed in a dark computer station somewhere else in the hospital. The physicians were too busy with the throughput that constitutes modern hospital care that they could not spare the time to attend their patient in his most personal moment. They missed a chance to be a part of the wonderful humanity of medicine. They simply felt they did not have the time. Such a situation is dehumanizing, not to the patient, but to the physician. Furthermore, dehumanization breeds an attitude MAY/JUNE 2019
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Physician Wellness vs Burnout of resignation that is self-perpetuating. Our current physician workforce is feeling these pressures. 54.4% of America’s Internists report symptoms of burnout, increased by 20% since 2011. according to a report from the Mayo Clinic. The rate is highest in doctors with larger clinical workloads. The overall effect on the physician psyche is reflected in the number who said they were dissatisfied with their work/life balance, increasing from 36.9 to 45.5%. These are the doctors who are also the mentors for the physicians of the future. Bad attitudes can be taught as well as good ones. When asked what bothers them most, doctors frequently cite the EMR. It is right to see the EMR as an intrusion into the doctor patient relationship. It is wrong to believe that computerization of medical records will go away. Electronic medical records are like swimming in ice water. Either you get used to it, or you drown. Rather than resisting, the only path forward is to make it better. EMR discomfort is a symptom not a root cause, however. The source of physician dissatisfaction is not such a superficial one. It cannot be cured with a pedicure. Efforts to improve doctor’s “quality of life” with better perks, improved EMRs, and even more money, are doomed to failure if no one pays attention to a more fundamental issue. A deeper, more troubling disconnect expressed by burned-out doctors is the feeling that they are simply “cogs in the wheel”. It is that troubling sense of inability to be the best you can be as a doctor that, for type A individuals like us, gnaws away at our sense of self. Cogs are devoid of personality, of humanity. This is the worm in the soul of modern medicine – the increasing depersonalization experienced by both the patient and the health provider. Space precludes me from offering a solution, but I will try to sketch the scenario: Somehow the patient and the doctor need time to reconnect, especially in moments of illness or crisis. Technologic assistance in the doctor/patient relationship needs to be tailored to each patient’s particular needs and values. The unique skill of the physician should be in that assessment. More time spent between patient and doctor will not only reaffirm the doctor’s sense of professionalism and enhance the patient’s sense of trust, but it could also increase diagnostic accuracy while significantly reducing use of unnecessary technologic (read expensive) interventions. Such a change will require leaders with vision not ego. Physicians cannot go it alone; the demon is too far out of the box. Real change begins with the realization that organized medicine picked the wrong partner in the 1980’s to fix the problems of health care financing. Rather than partnering with their natural allies, their patients, doctors fell prey to the promises of a quick and profitable fix from the hospital and insurance industry. We watched in disbelief as funding structure after funding structure only resulted in increased profits for the medical industry, stable to declining incomes for physicians, and the increasingly dysfunctional and bloated health care industry that is still unable to care for all of its citizens. Good job for technology without heart. Calling for more humanity in Medicine is a pretty weak response. I’m not sure, however, that our medical leaders have the wisdom or courage to reject the sweet relationships they have 20
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forged with legislators, insurers, and health systems. We may need to change them in order to change the system. Instead, the local medical societies need to create alliances of common interest with the wide diaspora of patient groups in our communities. The goal should be to develop a system that works best for the end user and recipient - the patient and the doctor. Top-down programs like we keep trying to impose rarely work. They only seem to enrich the imposer and homogenize the system to a level of equally distributed dissatisfaction. Patients want a more humane relationship with their health care provider. We, the doctors, need it. Society will benefit from it. These are three planks of common cause on which to move forward.
Dr. Bill Andereck is a previous editor of San Francisco Medicine and former trustee of the California Medical Association. Since 2003, he has been the Director of Sutter Health’s Program in Medicine and Human Values, providing clinical ethics consultations in nine Sutter hospitals in Northern California. He continues to practice Internal Medicine in San Francisco.
References 1. Korhonen was not his real name, but as you may know, it is the most common surname in Finland.
WHO recognizes burnout as a disease May 28-2019 - The World Health Organization (WHO) for the first time put burnout on its International Classification of Diseases (ICD) list, which is used globally as a benchmark for health diagnosis. The international body reached the decision to categorize burnout as a medical condition during its recently concluded World Health Assembly in Geneva. Following recommendations from health experts around the world, the updated ICD list was drafted in 2018 and was approved. The WHO has now classified burnout as "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed." The global health organization said the burnout syndrome is characterized by three dimensions: "1) feelings of energy depletion or exhaustion; 2) increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and 3) reduced professional efficacy." "Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life," according to the classification. WWW.SFMMS.ORG
Physician Wellness vs Burnout
The Mosaic
A FAREWELL TO A FELLOW FUTURE PHYSICIAN Shakkaura Kemet, MPH The Mosaic is a piece of writing I did to process the death of our classmate, Colin Alexander. It’s how I said goodbye to him, and one of the first times I paused to process the culture of med school after classes started. I imagined the night we were notified of our classmate’s death at least a decade before it happened. I always knew I would be a physician, and often when I would share my career aspirations with peers as a child, they would recoil at even the idea of being woken up in the middle of the night to tend to patients. But I have always believed that it would be an absolute pleasure and honor to be the person called in the middle of the night to save a life, my faculties foggy only for a moment as I answered the midnight phone call. My patient needed me desperately. Never in my romanticized imaginings did I sleep through that midnight phone call, but that is what happened in reality. This was the first omen that this milestone of my medical career would not go as I had foreseen. I slept through the dozen calls I received from my classmates in the hour after Colin’s death was publicized to the class. When I did wake at 3 a.m. and glance at my phone, I immediately knew something was wrong. The telltale signs of missed phone calls and ominous “have you heard the news?” texts were all there glowing quietly at me in the darkness of by bedroom. The email in my inbox only confirmed what I already knew to be true: tragedy had struck UCSF. One of my fellow classmates had died. It is exceedingly difficult to express the ways in which the stresses of life manifest, peculiarly in medical school. Life in general can be hard. Life in medical school is hard, and also distorted. Normal ravages present with atypical manifestation. A classmate who takes to studying with newfound devotion of unknown etiology could simply have found new inspiration, or be burying depression under work. The sadness inherent in devoting one’s life to standing at the razor edge of life and death can be transient and ultimately illuminating, or it can take root in the mind and metastasize to the heart and soul. We are often exhausted, elated, terrified, and overwhelmed all in the same moment. And yet in the midst of all this, our conversations can become stenotic, narrowing to the scope of what we can manage to express in words. In a community as close and caring as UCSF School of Medicine, my peers and I adapted to this precarious environment by caring for each other. Only several weeks into medical school we were paradoxically already all attendings on the “medical student ward” of Moffitt hospital. Each of us is a patient on the service of our classmates. 22
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Thus, the news of Colin’s death represents the milestone I imagined years ago: the first midnight phone call regarding one of my patients. However, there was no room for a stealthy hero’s exit into the night to beat back the specter of death. The time for that had passed. Instead, we must visit our mosaics. At any given point in time, every physician is a mosaic of all the patients they have cared for up until that moment. This mosaic is our greatest asset in our work. Every new patient adds color, depth, and breadth to the mosaic, evolving our understanding of what it means to devote our lives to meeting people at the aching center of their humanity. Some things are too beautiful to be viewed routinely. Rather, the mosaic lives in the recesses, accessed mostly by our subconscious. Only rarely, on occasions in which we must add to this internal mural, do we consciously seek it out. It is with trembling hands that I approached my own mosaic, and added Colin’s contribution. Many in my class have experienced true grief at the idea that Colin will never practice medicine and see patients with us. I nod in agreement with their comments, and truly sympathized with their pain. And yet – I’ll say that I know that Colin will see patients. As a piece in each of our mosaics, he will be an invaluable part of every patient visit each one of us has over the course of our careers. Colin, I look forward to continuing our work together. Until then, Shakkaura
Shakkaura Kemet, MPH, completed her Bachelor’s degree at Harvard and a Master's of Public Health at Yale University. She is currently a second year medical student at UCSF School of Medicine where she is co-president of the Students’ National Medical Association, and teaches a course to first- and second-year medical students about integrating advocacy work into one's medical career. (The original version of this essay appeared in the UCSF Synapse.)
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DOCTORS FACE A DILEMMA WHEN SEEKING MENTAL HEALTH ASSISTANCE FOR THEMSELVES ‘Rebuilding More of Me,’ an essay published in JAMA, prompts an unexpected, national response.
Ellen Goldbaum It’s no secret that physicians have stressful jobs. Figuring out how to mitigate and deal with that stress can be a key part of a successful medical career. But while individual physicians seek and find help for their mental health issues privately, the prevailing public perception among physicians is that it just isn’t done. Sourav Sengupta, MD, knows all about that. An assistant professor of psychiatry and pediatrics in the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo, he reached a point a few years back where he knew that escalating professional and personal demands were impacting his effectiveness. Last month, JAMA Network online published his essay, “Rebuilding more of me,” about how he worked through his issues with the help of a therapist. He wasn’t sure how it would be received, but in the few weeks since its publication, he has received personal email messages from dozens of physicians from across the U.S. who reached out to share perspectives and their experiences. Since publication, Altmetric rated the essay in the top 5% of publications; it has been viewed more than 6,500 times and downloaded more than 500 times. Sengupta has received emails from physicians at every career stage, who tell him it was a relief to read it, to know that others have also gone through this and have succeeded. ‘I am an attending physician in the field from which I seek support’ The essay describes the difficulty Sengupta felt in figuring out how to access the help he needed. “I am an attending physician in the field from which I need support,” he wrote. “Many of the best clinicians and treatment setting are not options. I know them too well.” Once he found a psychotherapist he could work with confidentially, who wasn’t a colleague, he began to open up. Sengupta wrote: “His willingness to acknowledge that clinical work is stressful and can become toxic establishes a life raft upon which I can hoist myself, build new strategies, and shape a different perspective.” That struggle is behind Sengupta now and he was ready to move on. Besides occasionally discussing his experience with others who might be going through something similar, he didn’t consider sharing it more widely. He changed his mind when the Jacobs School held an event on National Physician Suicide Awareness Day. Alarming statistics were discussed, for example, that among physicians ages 25 to 39, suicide accounts for 26% of deaths compared to 11% in the same age group in the general population. The event struck a chord. As Sengupta listened to the discussion that followed the screening, he realized he needed to share his story. “One of the most distressing themes in the discussion afterwards was how scared or resistant or hesitant the trainees were about seeking any therapeutic support,” he recalled. “I wrote the essay for a very particular reason,” he said. “There were hundreds WWW.SFMMS.ORG
of trainees in the room but the vibe around seeking support was quite negative. It wasn’t that people thought physicians shouldn’t get help, but that there were lots of factors that would probably keep them from seeking help, such as stigma, having enough time, concern for how it might impact their careers. I wrote the essay in the hope that I could convey to other physicians what actually happens when you work with a therapist, that it’s a collaborative process that can lead to really positive outcomes.”
Self-stigmatization
Among the factors contributing to physicians’ reluctance to seek help are the traits that led them to medicine in the first place, Sengupta said. “Who is the type of person that ends up wanting to be a physician and then succeeding?” Sengupta asked. “We are pretty intelligent and we’re hard-working but we are probably not talking about the struggles we’re having. We’re internalizers.” At the same time, the nature of medical training itself also contributes. “The training values toughness and grit and perseverance. That shouldn’t be to the exclusion of getting help and support but somehow it can be translated into that. Taking care of oneself can seem to represent weakness or incompetence.” He knows, however, that the challenges to changing the culture are significant. For one thing, he said, trying to find someone who can help is complicated and sensitive. “How interesting would it be if we created some sort of way for physicians who are struggling to communicate with each other… a support group of sorts?” In the essay, he describes how he shared his experience with his trainees; it came up in the context of a broader conversation about self-care. Afterward, he noticed a change in the way they interacted with him. “I sense a subtle shift in the way some of them approach me. A bit more willing to discuss challenges and vulnerabilities. More open to reflection and self-improvement. A few clinicians even ask for help in finding therapists for themselves, allowing me to transform my process of seeking help into a way to help others.” Ellen Goldbaum is Senior Medical Editor, University at Buffalo.
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Physician Wellness vs Burnout
MEDICAL ERRORS MAY STEM MORE FROM PHYSICIAN BURNOUT THAN UNSAFE HEALTH CARE SETTINGS Tracie White Physician burnout is at least equally responsible for medical errors as unsafe medical workplace conditions, if not more so, according to a study led by researchers at the Stanford University School of Medicine. “If we are trying to maximize the safety and quality of medical care, we must address the factors in the work environment that lead to burnout among our health care providers,” said Tait Shanafelt, MD, director of the Stanford WellMD Center and associate dean of the School of Medicine. “Many system-level changes have been implemented to improve safety for patients in our medical workplaces. What we find in this study is that physician burnout levels appear to be equally, if not more, important than the work unit safety score to the risk of medical errors occurring.” The study was published online July 9 in the Mayo Clinic Proceedings. Shanafelt, who is also a professor of hematology and the Jeanie and Stew Ritchie Professor, is the senior author. Daniel Tawfik MD, an instructor in pediatric critical care medicine at Stanford, is the lead author.
A national epidemic
Medical errors are common in the United States. Previous studies estimate these errors are responsible for 100,000 to 200,000 deaths each year. Limited research, though, has focused on how physician burnout contributes to these errors, according to the new study. The researchers sent surveys to physicians in active practice across the United States. Of the 6,695 who responded, 3,574 — 55 percent — reported symptoms of burnout. Ten percent also reported that they had made at least one major medical error during the prior three months, a figure consistent with previous published research, the study said. The physicians were also asked to rank safety levels in the hospitals or clinics where they worked using a standardized questionnaire to assess work unit safety. “We found that physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for spe24
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cialty, work hours, fatigue and work unit safety rating,” Tawfik said. “We also found that low safety grades in work units were associated with three to four times the odds of medical error.” Shanafelt said, “This indicates both the burnout level as well as work unit safety characteristics are independently related to the risk of errors.” Physician burnout has become a national epidemic, with multiple studies indicating that about half of all doctors experience symptoms of exhaustion, cynicism and feelings of reduced effectiveness. The new study notes that physician burnout also influences quality of care, patient safety, turnover rates and patient satisfaction. “Today, most organizations invest substantial resources and have a system-level approach to improve safety on every work unit. Very few devote equal attention to address the systemlevel factors that drive burnout in the physicians and nurses working in that unit,” Shanafelt said. “We need a holistic and systems-based approach to address the epidemic of burnout among health care providers if we are truly going to create the high-quality health care system we aspire to.” The study also showed that rates of medical errors actually tripled in medical work units, even those ranked as extremely safe, if physicians working on that unit had high levels of burnout. This indicates that burnout may be an even a bigger cause of medical error than a poor safety environment, Tawfik said. “Up until just recently, the prevailing thought was that if medical errors are occurring, you need to fix the workplace safety with things like checklists and better teamwork,” Tawfik said. “This study shows that that is probably insufficient. We need a two-pronged approach to reduce medical errors that also addresses physician burnout.” Tracie White is a science writer for Stanford Medical School’s Office of Communication & Public Affairs.
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Physician Wellness vs Burnout
MIEC’S APPROACH TO PHYSICIAN WELLNESS Michael D. Anderson, CPHRM In 2016 Stanford Medicine published a report of their Physician Wellness Survey, which consisted of responses from 1281 Stanford-affiliated physicians. This survey queried providers regarding their perceptions of professional fulfillment, burnout, culture of wellness, efficiency of practice, personal resilience, and support from leadership. Key findings of the survey revealed the following: • 34% of physicians reported one or more symptoms of burnout, such as emotional or physical exhaustion
• 44% reported some amount of professional fulfillment, but only 17% reported a high degree of fulfillment
• Compared with their male colleagues, female physicians reported lower professional fulfillment (37% vs. 51%) and higher burnout (39% vs. 28%) • Overall burnout rates had increased, and fulfillment was decreased, from 2013 to 2016
• Low self-compassion and sleep deprivation were the two strongest factors contributing to physician burnout
• Culture of wellness factors were the strongest determinants of professional fulfillment
• Experience with efficiency of EMR was a significant factor in fulfillment and burnout
As an insurer of medical professional liability and an advocate for all healthcare providers, MIEC is dedicated to improving the overall well-being of physicians and preventing burnout. This is an issue that impacts not only the quality of medical care and malpractice liability, but also patients’ access to care as our nation continues to experience provider shortages. It is critically important to ensure that physicians can sustain long, successful, and healthy careers spent caring for those in need. MIEC’s approach to physician wellness is twofold. First and foremost is our everyday work- we support physicians by providing comprehensive liability protection, vigorously defending claims, assisting with various legal and practice-related questions, and providing education and customized assistance to improve patient safety and reduce risk. This collaborative approach to protection allows physicians to worry about less, and to focus on patient care. In the course of defending claims, MIEC staff works closely with defense attorneys to support physician defendants in all aspects of their experience. Often, defendants rely on the expertise of their attorney and claims representative to help them to understand the nature of the case and its defensibility, to make decisions about resolution, and to provide professional and emotional support during the case. WWW.SFMMS.ORG
However, physicians often find malpractice claims to be one of the more difficult experiences of their careers; sometimes, they experience sufficiently severe stress from litigation that they need additional support. MIEC works closely with our partner medical societies, including SFMMS, to provide litigation stress support services such as peer-to-peer counseling. Additionally, we conduct periodic seminars on the stress of litigation, which are open to all medical society members and which involve presentations by a medical malpractice defense attorney, a former physician defendant, and a physician expert in litigation stress counseling. These open discussions are often cathartic for those who have experienced a malpractice claim, and reassuring for those who have not yet had a claim. MIEC will be working with SFMMS to present litigation stress programs in 2019; look for event announcements in the coming months. Second, MIEC has developed a Physician Wellness portal on our website (www.miec.com/wellness/) that includes multiple self-directed resources, including the Mayo Clinic Physician Well-Being Index. Our goal in developing the Physician Wellness portal was to help physicians cut through the clutter and provide effective wellness resources for the busy healthcare professional. The Wellness portal is available to anyone who visits MIEC’s website. Physicians are encouraged to begin with the Well-Being Index, which is an anonymous, web-based tool consisting of nine questions designed to evaluate multiple dimensions of stress. The Index is designed to measure burnout, provide valuable resources, and allow users to compare their scores to their peers as well as track progress over time to promote self-awareness. By completing the survey, physicians receive instant feedback including their Well-Being Index score, and comparative analysis to physicians nationally across a variety of categories. In addition, scores of those participating through the MIEC Wellness Portal can view anonymous comparisons to the average scores of their peers. Physicians can reassess and track their Index periodically to see if their score has changed over time. After completing the Well-Being Index, physicians can explore MIEC’s wellness portal to find relevant, reliable, and vetted resources to start the journey to improved wellness. These resources include the Mayo Clinic Physician Health Center, The Burnout Prevention Matrix, and state-specific resources such as the CMA’s Well Physician California program. MIEC is committed to providing physicians the tools necessary to effect change in both their personal and professional lives and allow them to focus on patient care. Michael D. Anderson, CPHRM, Supervisor, Patient Safety & Risk Management, Medical Insurance Exchange of California. MAY/JUNE 2019
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CMA CANDIDATE’S STATEMENT
HEALTH POLICY AS A PASSION
LAWRENCE CHEUNG, MD
Past President of SFMMS and a candidate for CMA Vice-Speaker in 2019 I f i r s t b e c a m e i nvo lve d w i t h organized medicine when I was a first year medical student at the College of Physicians and Surgeons of Columbia University. At that time, hepatitis B was a silent epidemic in the in the Asian community but it was not on the general medical community’s radar. When I became aware of the problem, I, along with a handful of other medical students, decided to form an organization to specifically deal with issues relevant to the Asian American Islander American community. We formed the Asian Pacific American Medical Student Association (APAMSA), an organization that continues to be a thriving organization to this day (more than twenty years after its founding). I presided as the first full term national president and I made hepatitis B screening and education a priority health care issue. After graduating medical school, I was extremely fortunate to match in the primary care internal medicine program at UCSF. I had my career mapped out in front of me. I was to finish internal medicine residency, then proceed to a general medicine fellowship, and then followed by a career in the Department of Public Health. However, what I came to realize was that I was more interested in crafting policy rather than executing it. That epiphany made me reconsider my career pathway and ultimately I left internal medicine to pursue dermatology, a field that I have always loved. But I never abandoned my passion for public health care policy. I realized that I would be more effective as a public health policy leader within organized medicine, where we can engage local, state, and federal lawmakers in crafting evidence-based public health policy. To that end, I became an active member of the San Francisco Marin Medical Society when I established my practice in 2005. I have had the privilege of serving as SFMMS president
in 2014 and over the years, I have engaged local, state and federal law makers in crafting evidence-based public health policy. I am most proud to have worked on issues such as a sugar sweetened beverage tax, a ban on the sale of flavored tobacco products, common sense firearm policies, and the defense of MICRA (Medical Injury Compensation Reform Act). I currently serve on the CMA Council on Science and Public Health, a role in which I help craft public health policy for the CMA. More importantly, I serve as the Chair of our District VIII Delegation to the CMA. In this position, I help to move forward resolutions from our county to be adopted as official CMA policy. Most importantly, I serve as our California Resolution Committee Chair of our CMA delegation to the AMA, where I help champion CMA policy to be adopted as AMA policy. I decided to enter the race to be the CMA Vice-Speaker because I believe in the importance of policymaking. California leads the nation in innovative policy and it is no different in health care policy. As the Chair of our District VIII Delegation, I have seen first-hand the CMA House of Delegates adopt pioneering and leading edge policies that go on to become AMA policies. As Vice-Speaker, I will be first and foremost, fair and neutral. I believe in the collective wisdom of our House of Delegates but I will make sure that all sides of the debate are heard and that no opinions are censored; I will be the fireiest champion and protector of our House. This is a tough but worthwhile job and it will be a privilege for me to serve as the next Vice-Speaker of the CMA House of Delegates. Dr. Cheung is Chairman of the SFMMS delegation to the CMA and a past-president of the SFMMS.
Please join us for the Annual David E. Smith, MD Symposium:
“Psychedelic Medicine, Technology and Conscious Recovery” Friday, June 28th, 2019 at the UCSF Mission Bay Conference Center • Attendees can earn 7.0 CEs. Be a part of recovery history. Join Dr. Smith and his colleagues, all cutting edge thinkers and practitioners, for The Annual David E. Smith, MD Symposium — a day of learning, discovery, and discussion. Few have done more to shape the field of addiction treatment and recovery than Dr. David E. Smith. Since starting the Haight Ashbury Free Clinic during the Summer of Love in 1967, Dr. Smith remains at the forefront of understanding culture’s relationship with substances, its implications on mental and physical health, and effective treatment approaches. Each year, this symposium brings together leading experts working to develop the research, technologies, and treatments that are shaping the field of addiction treatment. This year, we have eighteen speakers from a variety of fields and backgrounds. Topics include an authoritative review of the resur26
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gence in legitimate psychedelic therapies and research, updates on medicationassisted treatment, neuromusicology and recovery, technological advances in the treatment of addiction, expert perspectives on trauma and conscious recovery, updates on approaches to substance use disorder education in the medical system and the emerging workforce of dedicated addiction professionals. Be a part of the dialogue that may inform tomorrow’s therapies, learn about new and effective treatment modalities, and mix and mingle with peers, friends, and colleagues. Attendees can earn 7.0 Continuing Education units, cost is included with registration. Registration is limited. Please reserve your space now. To learn more and register please follow the link: https://www.drsmithsymposium.com/register WWW.SFMMS.ORG
Physician Wellness vs Burnout
EVIDENCE-BASED HEALTH POLICY IN ACTION:
THE SFMMS DELEGATION TO THE CMA AND AMA
Michael Schrader, MD and Steve Heilig, MPH
Many if not most physicians tend to be somewhat apolitical, by temperament and training. But they also tend to truly care about policies where medical practice and patient and public health are impacted, for better or worse. That’s where “organized medicine” provides a platform for advocacy of evidencebased, compassionate, rational medical and health policy. And the SFMMS is quite good at that. Modeled on our broader political system, county medical societies elect representatives to the state (CMA), and national (AMA) groups. The SFMMS has a tradition and image of bringing forward-thinking, often controversial policy ideas to these broader groups, and for getting them adopted and promulgated. Many standing state and national policies on issues such as reproductive health, end-of-life care, HIV, tobacco, obesity, drugs, guns, and other weighty concerns originated at the SFMMS, and were fought over and prevailed due to SFMMS representatives’ expertise and eloquence. If we sound proud of this tradition that’s because we are. The CMA House of Delegates (HOD) is our yearly forum for forming and promoting medical policy. The HOD consists of nearly 500 delegates elected by county medical societies, specialty societies, and others statewide. During this annual meeting major issues are debated, amended, and voted on for adoption or dismissal. CMA leadership is also elected and inaugurated. The SFMMS District VIII delegation, whose size is based upon membership numbers (there is no electoral college here), is comprised of 14 delegates and 14 alternate delegates who collectively occupy 14 voting seats. We also have an active UCSF student and resident section. Our tradition has been to actively shuffle delegates and alternates into these seats so that all may participate. Our delegation meets during the year to review proposed resolutions, come to some consensus and discuss strategy. There is also time for socializing, meeting new friends, and renewing old acquaintances. A couple new delegates recently remarked “I love these meetings – there’s nothing else around like them!” Last year in Sacramento we were a focal point for a change in the top CMA leadership with the election of our own Dr. Peter Bretan to President-elect. It was a close contest between three worthy candidates. Peter’s inspiring message was about his own calling to medicine and our obligation to give back. The initial vote resulted in a runoff. The second vote was close but Peter had won the hearts of the delegates and prevailed. We all left the meeting with a feeling of hope and promise. We look forward to inauguration of Dr. Bretan to CMA President at the upcoming CMA HOD in October. WWW.SFMMS.ORG
As usual, we had success with some of our policy resolutions as well. Resolutions are submitted quarterly for consideration by the CMA Board of Trustees. Resolutions can be drafted by any member and submitted with the help of our delegation (to strengthen language and to give delegation support). Resolutions are then debated online with standing councils weighing in with their revisions. This is then debated openly online again by the entire body of delegates and then submitted to the Board of Trustees for final approval. We now have two resolutions that the CMA Board of Trustees recently adopted: “Gun Violence - Compensation for Healthcare Expenditures” and “Holding the Pharmaceutical Industry Responsible for Opioid-Related Costs.” Both of these are timely as it appears these ideas are moving forward in the public arena, although the gun resolution was “watered down” to favor more safety features – still a worthy aim. We also have submitted three current resolutions addressing the detention and abuse of migrant children, reducing barriers for physicians to prescribe buprenorphine, and suspension of e-cigarette sales prior to FDA review of their safety. Again, some of these seem to be ahead of the curve of public action, with growing support. This year the HOD plans to address the health consequences of legal marijuana, the impact of adverse childhood events, health consequences and costs of homelessness, and artificial intelligence and emerging technologies. . We anticipate a new age of cooperation and influence with newly elected California Governor Gavin Newsom, who recently told CMA he hopes and intend to be the “Health care Governor.” Last but certainly not least, we look forward to a spirited campaign by our delegation chair Dr. Lawrence Cheung for Vice-Speaker of the CMA HOD, a demanding and very important position for which we know he’d be superb!
SFMMS delegation chairs Drs. Michael Schrader and Lawrence Cheung, flanking recent UCSF graduate Dr. Rachel Ekaireb, former student delegate to CMA and now a surgical resident at UC Davis.
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Courtesy of CMA
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Why Radiology Residents Experience Burnout and How to Fix It Burnout among radiology residents is among the highest compared to other medical subspecialties, with 85 percent of trainees feeling emotional exhaustion, depersonalization and decrease feelings of personal accomplishment. Dexter Mendoza, MD, and Frederic Bertino, MD, of the department of radiology and imaging at Emory University in Atlanta, may have ways to combat it. To reduce residency it, the authors suggest radiology programs should implement the following:
• Prioritize resident health and wellness by creating an inclusive program that focuses on physical activity, stress management and diet. • Prioritize mental health through establishing and recommend counseling and support services for employees. • Facilitate efficiency by investing in informatics, artificial intelligence and a technology support team.
• Build on residents’ competence and confidence through regularly administered constructive feedback. • Empower and promote the autonomy of residents by decreasing levels of supervision for trainees.
• Help residents discover and realize their passions through efforts to optimize career fit and promote professional and personal satisfaction. • Recognize and celebrate success.
• Celebrate diversity, promote inclusion and foster a sense of community among the residents inside and outside their training program. • Increase open communication and transparency to empower residents to seek change and solutions that can improve the program and radiology department. Source:
Why Radiology Residents Experience Burnout and How to Fix It Mendoza, Dexter et al. Academic Radiology , Volume 26 , Issue 4 , 555 – 558 April 2019
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WELCOME TO OUR NEW SFMMS/CMA MEMBERS: Pilar Abascal, MD | Psychiatry Melinda Aquino, MD | Vascular Surgery Veronique Au, MD | Emergency Medicine Susan Bailey, MD | Vasular Surgery Anita Barzman, MD | Psychiatry Karen Bayle, MD | Internal Medicine Jon Boone, MD | Psychiatry Dylan Carney, MD | Emergency Medicine Patricia Cavero, MD | Cardiovascular Disease David Chang, MD, FACS | Plastic Surgery Warren Choy, MD | Internal Medicine Wei Diao, MD | Family Medicine Sal Fazio, MD | Internal Medicine Daniel Fentress, MD | Family Medicine Allison Friedenberg, MD | Pulmonary Disease Srinivas Ganesh, MD | Internal Medicine Neha Garg, MD, MPH | Nephrology Jonathan Gee, MD | Internal Medicine Silpa Goriparthi, MD | Anesthesiology David Grunwald, MD | Psychiatry Anjali Gupta, MD | Physical Medicine and Rehab Steven Hao, MD | Clinical Cardiac Electrophysiology Lucas Harless, MD | Head and Neck Surgery Fatima Hassan, MD | Pediatrics Jeffrey Lee, MD | Internal Medicine On-Tat Lee, MD | Ophthalmology Kenneth Leong, DO | Internal Medicine
Alan Leung, MD | Internal Medicine Brett Ley, MD | Internal Medicine James Lin, MD | Internal Medicine Jessica Matchett, MD | Obstetrics and Gynecology Gina Moreno-John, MD, MPH | Internal Medicine Nizar Mukhtar, MD | Internal Medicine Sirisha Nandipati, MD | Neurology Kirk Pappas, MD | Physical Medicine and Rehab Kinnari Patel, MD | Anesthesiology Ali Poyan Mehr, MD | Internal Medicine Simi Pullukat, MD | Pediatrics Judryn Racines, MD | Internal Medicine Dorota Rhoades, MD | Family Medicine Susannah Rose, MD | General Surgery Farah Siddiqui, MD | Physical Medicine and Rehab Larissa Thomas, MD, MPH | Internal Medicine Monica Tse, MD | Internal Medicine Tiffanie Tse, MD | Pediatrics Jeffrey Tseng, MD | Radiology Christopher Tyler, MD | Critical Care Medicine Lam Vo, DO | Hospitalist Rebecca White, MD | Pediatrics Maud Wilson, MD | Pediatrics Andrew Wisneski, MD | General Surgery Ashley Young, MD | Obstetrics and Gynecology Justin Yu, MD | Internal Medicine Chao Yuan, MD | Emergency Medicine
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UPCOMING EVENTS San Francisco Addiction Summit, 6th Annual David E. Smith, MD Symposium Friday, June 28, 2019, 7:30am-6:00pm | UCSF Mission Bay Conference Center, San Francisco, CA Join Dr. David Smith and other addiction specialists and professionals for a one-day symposium. Our forward-thinking speakers will present an authoritative review of the new resurgence in legitimate psychedelic therapies and research, updates on medication-assisted treatment, neuromusicology and recovery, technological advances in the treatment of addiction, expert perspectives on trauma and conscious recovery, updates on approaches to substance use disorder education in the medical system, and the emerging workforce of dedicated addiction professionals. For more information, visit https://www.drsmithsymposium.com/.
2019 NEPO Summit August 23-24, 2019 | Pasadena, CA
The 2019 Network of Ethnic Physician Organizations (NEPO) will be held August 23-24 in Pasadena. This year’s theme is Standing Up for Health Care in California. The twoday summit is an innovative educational event for physicians, public health professionals, advocates and community leaders that offers policy and best practices for reducing health disparities, building diversity in the workforce and increasing cultural competency in clinical care. See more information at http://bit.ly/2LNh25v.
SFMMS General Membership Meeting September 9, 2019, 5:30pm | Golden Gate Yacht Club, San Francisco, CA
Calling all SFMMS members: Join us at our General Meeting on September 9, 2019. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMMS leadership and to learn firsthand the issues SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco, Marin and California. Details will be available soon at www.sfmms.org. RSVP to Erin Henke, ehenke@sfmms.org, (415) 561-0850 x268.
SAVE THE DATE – 2020 SFMMS Annual Gala Friday, January 31, 2020, 5:30-9:30pm | Green Room at the SF War Memorial, San Francisco
The 2020 SFMMS Annual Gala will be held on Friday, January 31, 2020 at the Green Room at the San Francisco War Memorial. President-Elect, Brian Grady, MD will be installed as the 2020 SFMMS President. More information and registration will be available soon at www.sfmms.org/events.aspx. Sponsorship opportunities are available – contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268. 32
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COMMUNITY NEWS KAISER PERMANENTE
Maria Ansari, MD The stresses of practicing medicine have grown dramatically over the past decade. National data indicates that the burnout rate among physicians is more than 50 percent and the suicide is also higher for physicians than for other professions. In the United States, we’re losing one doctor a day to suicide which is a national tragedy. In addition to this being a very serious concern, physician burnout also impacts the quality and cost of care, and ultimately the number of physicians available to care for our populations in the future. Stressed physicians have overall lower productivity, and physician burnout can contribute to high turnover rates, early retirement, medical errors, and malpractice risk. Here at Kaiser Permanente, we believe that physicians who are healthy in body, mind, and spirit are better equipped to help their patients achieve similar outcomes. When you offer support for those who provide care, they’re able to give better care. Within The Permanente Medical Group, we have many different programs and initiatives to support our physicians. Every medical center has a chief of Physician Wellness and we have a regional director of Wellness Operations for Northern California. Our employee assistance program includes a licensed psychologist who is available to meet with physicians individually with complete confidentiality, and physicians have coverage to seek help outside the workplace as well. Counselors are available to come into the clinic and support a team faced with a challenging case or the trauma of an unexpected outcome. Our regional program, “Care for the Caregiver, “supports physicians who may be involved in a lawsuit. We offer leadership training for all physicians regardless of tenure which includes both professional development and personal growth. We are helping those involved in operational decision-making to lead with an eye to wellness and create policies and systems that foster an environment supportive of physician wellness and resilience.
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