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AMA

Moving Medicine

Magazine | Summer 2019

Changing the culture of burnout LOOKING UPSTREAM FOR ANSWERS + THE POWER OF THE KITCHEN TABLE CONSULT + A QUEST TO NEVER WASTE A STEP + WELL-BEING 101: ELEVATE THE CONVERSATION + REVEALING THE RIPPLES OF BURNOUT


President’s note . . . . . . . . . . . . . . . . . . . . . 3 By the numbers . . . . . . . . . . . . . . . . . . . . . 4 Insider access . . . . . . . . . . . . . . . . . . . . . . . . . . 6 End note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

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Looking upstream for answers

The power of the kitchen table consult

In any field that requires not just a time commitment, but an emotional investment in your work, your cup can only be so full.”

This is a cultural journey over three to five years.”

— Kavita Arora, MD, MBE, MS

— Nigel Girgrah, MD

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A quest to never waste a step

All the changes we made in our practice came out of a similar impulse to maximize the enjoyment of the work, and doing work that mattered.” — Christine Sinsky, MD

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Well-being 101: Elevate the conversation

People are reluctant to come forward because of the career impact they fear it will have.” — Jeffrey P. Gold, MD

Revealing the ripples of burnout

Physicians expect and want to work hard, but they need to do so in efficient systems that support, rather than hinder, their efforts.” — Lotte N. Dyrbye, MD

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From the desk of:

Patrice A. Harris, MD, MA Physician burnout is a major issue. Our AMA cast a spotlight on burnout and spurred a movement to address it. AMA members and physician leaders are on the front lines of developing research, interventions and strategies that provide relief for physicians who too often have been told to rely exclusively on building resilience, reducing stress or other individual-level strategies. We have moved past the days of “physician, heal thyself” by successfully advocating for organizational and systemic change. We have seen a reduction in burnout rates among physicians for the first time in three years, but there is still much work to be done. In this, our second issue of 2019, we explore the many sides of professional burnout—from organizational transformation and ongoing research on solutions to the impact of burnout on personal relationships. Our Summer 2019 issue of AMA Moving Medicine is a reaffirmation of our commitment to changing the conversation around burnout and its impact on patients, physicians and the profession. I hope you enjoy this latest issue of AMA Moving Medicine, and thank you so much for being a member of the AMA. Patrice A. Harris, MD, MA President American Medical Association

AMA Moving Medicine Magazine Summer 2019 Publisher Todd Unger Executive editor Ryan Wells Editor Jef Capaldi Staff writers Sara Berg Tanya Albert Henry Brendan Murphy Kevin B. O’Reilly Timothy M. Smith Design directors Debra Berk Aly Schweigert Designers Bobby Reichle Sara Tomeo Photographer Jeff Schear Project manager Colin Smith Special thanks to the following: Sarah Clevenger James Gilligan Ray Helm Kristin Reynolds Loz Ross Kristen Tinney Eileen Sladky

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By the Numbers

System distractions can lead to burnout Did you know that most physicians spend 30% of their time documenting progress notes? The following administrative hassles tend to take away from time spent with patients and lead to stress and emotional exhaustion:

3.17 hours

logged on average for desktop medicine each day

Physicians spend up to

86 minutes

of pajama time nightly with EHRs

Only 27%

of a physician’s day is spent meeting one-on-one with patients Source: American Medical Association

Burnout is greater among physicians than in most other professions Given the unique administrative burdens physicians face, it’s no surprise that burnout is a larger issue for health care professionals than it is in most other fields:

Burnout is nearly two times as prevalent in physicians than other U.S. workers

Burnout increased 9% in physicians from 2011-2014 while remaining stable in other U.S. workers

Compared to other U.S. workers of the same gender, suicide rates are: 130% higher for female physicians 40% higher for male physicians Source: National Academy of Medicine

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Insider access

When you’re busy caring for others, it’s easy to forget about your own mental health. But when you meditate with Headspace, you’ll always have peace of mind in your pocket. As the newest provider through the AMA Member Benefits PLUS program, Headspace is offering all AMA members a twoyear free subscription to Headspace.

• Headspace is a digital meditation app that can help you reduce stress and burnout, and increase resilience and happiness. Learn the life-changing skills of meditation and mindfulness in just a few minutes a day. Headspace has bite-sized meditations for busy schedules, SOS exercises for tough situations and hundreds of guided meditations on everything from stress to sleep.

•  Studies show it helps reduce stress and burnout in health professionals, while boosting happiness, compassion, resilience and satisfaction with life.

Learn more (members only) about how to redeem your AMA member benefit.

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Looking upstream for answers OCHSNER HEALTH SYSTEM’S FIRST CHIEF WELLNESS OFFICER, NIGEL GIRGRAH, MD, FOCUSES ON THE SOURCE OF STRESSORS TO GIVE TIME BACK TO HIS COLLEAGUES.

By Sara Berg

I

t started in May 2017 with a letter from the chief executive officer of Ochsner Health System in New Orleans expressing a call to action to address physician burnout. Three months later, the health system launched a provider well-being task force led by Nigel Girgrah, MD, a transplant hepatologist and medical director of the Ochsner Multi-Organ Transplant Institute.

Nigel Girgrah, MD Member since 2019

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One year after leading the task force, Dr. Girgrah reported findings to the executive team, expressing strongly that Ochsner needed a chief wellness officer and office of professional well-being to specifically focus on issues surrounding burnout. The executive leadership team agreed and asked Dr. Girgrah to fill the vital new role. “Dr. Girgrah values personal connections and the best interests of the physician group, as well as all employees,” says Francis Rodwig, Jr., MD, medical director of Professional Staff Services and medical director of Transfusion Medicine at Ochsner. “He is authentic in his relationships and he models the behavior of an emotionally intelligent leader.”

“I came to interview here nine months after Katrina. At the time, I wasn’t really looking to leave Toronto, but I was curious. I remember my father had once told me that it was his favorite American city,” he says, adding that he was drawn to the hospital’s culture, and the vibe of the city and community. It wasn’t until 2013 at his 20-year medical school reunion, though, that he stumbled into an interest in physician burnout and well-being. “I found out some alarming things about a couple of my med school colleagues having exited the profession in one way or another,” says Dr. Girgrah. “I probably hadn’t heard of burnout before, but that’s when I started reading about it.” With profound interest in learning more, his adjusted course led him down a new path toward chief wellness officer.

We always seem to talk about burnout as being binary—present or absent. The surveys report back on the percentages of burnout, but clearly, it’s fluid.” —Nigel Girgrah, MD

Executive Vice President and Chief Medical Officer at Ochsner, Robert Hart, MD, echoes Dr. Rodwig’s sentiments. “When we started the task force, it was very clear that he had a passion for this. If you spend much time with him, he has a very compassionate side,” says Dr. Hart. Dr. Girgrah was not always leading the charge against physician burnout. His medical journey started in Toronto where he completed his MD and PhD, but it was his “midlife crisis” that led him to New Orleans in 2007 where he was attracted to the culture, environment and community.

IDENTIFYING THE SOURCE OF THE PROBLEM Physicians often think they can do everything, but if they cannot do something they often blame themselves. He wants to send a message to physicians that “this is primarily a systems issue and that it’s not their fault.” “The few times burnout had been talked about, it always seemed to be talked about after a conversation about patient experience or after a conversation about quality and safety,” Dr. Girgrah says, adding that he always felt when burnout was discussed after these conversations, it “elicited some degree of cynicism, particularly on the part of the frontline physicians.” Instead of talking about burnout as the right thing to do, it was always just a means to an end. However, by addressing it, he believes other very important things around compassionate care, patient experience, quality and safety, discretionary effort and financial performance will follow. Because Ochsner did not know much about burnout, they began by surveying the group practice to understand the problem before finding a solution. “It was clearly a problem growing around the country and we recognized we were not immune from it,” says Dr. Hart. “I’ve been in health care as a physician for 30 years and clearly the demands have become greater. There are a lot of demands from physicians that have created this burnout and we recognized that among our own staff.”

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Clearly this isn’t going to be a journey where success is managed and measured in weeks or months. This is a cultural journey over three to five years.” —Nigel Girgrah, MD

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“We did the math with a survey a little over a year ago and we were a little bit better than the average across the country, but clearly it was something that we had to address for our physicians and advanced practice providers (APPs), as well as for our patients,” adds Dr. Hart. The Maslach Burnout Inventory was completed in August 2017, drawing from about 800 respondents. While Maslach was considered the industry standard at the time, Dr. Girgrah felt it was a cumbersome tool that required them to “go through it with a fine-tooth comb to get any sort of demographic data.” This survey highlights three primary dimensions of burnout— depersonalization, lack of personal accomplishment and emotional exhaustion. It also describes six dimensions in work-life centered around sense of community, values, control, rewards, reward recognition, fairness and workload. “We were doing reasonably well against national benchmarking in describing lack of depersonalization, a greater sense of personal accomplishment, a sense of community in the workplace and congruence of personal with organizational values,” says Dr. Girgrah. However, Ochsner was doing relatively poor in “describing more emotional exhaustion, sense of lack of control with a work environment, not being rewarded or recognized, and a fair and manageable workload.” After carefully looking at physician engagement surveys, he conducted three months of focus groups to begin taking the right steps toward improving organizational well-being. During his visits to different campuses with a variety of groups of physicians, he asked doctors what went into a good day at work, but also tackled what made for a bad day. “We always seem to talk about burnout as being binary— present or absent. The surveys report back on the percentages of burnout, but clearly, it’s fluid, it operates along a continuum, even within an individual and within departments,” says Dr. Girgrah.” While Dr. Girgrah was happy to see that Ochsner was not worse than the national average, there were five areas of opportunity with the first being respecting a physician’s time. To the extent possible, physicians want to spend more time with their patients or families. However, they also want to spend less time doing what is perceived as “menial rather than meaningful interactions,” such as clerical work.

The second theme in some departments—particularly for surgeons—was centered around having the fundamental tools to care for patients. Some surgeons found inconsistencies in the availability of tools needed for proper care. If they don’t have the right tools or environment to perform their daily duties, it makes being a surgeon more difficult. Knowing this, Dr. Girgrah wants to make sure they can escalate the problem and get what they need. The third area, that was not consistent throughout the organization, was around building the team. “Not just physicians and APPs, but everybody that interacts with the patient along the care continuum, so medical assistants, nurses, PharmDs,” he says. “There were variations in departments who had mature, highly functioning nurses and medical assistants who had been with their team for a long period of time. It was like, ‘what’s burnout?’ “Then you’d have a department that had rapid turnover of medical assistants, poorly defined scope of practice as medical assistants and nurses. Those departments were hurting,” Dr. Girgrah adds. “A fourth theme would have been around conflicting priorities,” he says. “One month, let’s focus and double down on patient access and then next month, let’s double down on financial production.” “We all recognize that health care is really complicated and there are many priorities, but from a level of the frontline physician, to the extent possible, they want us to focus what we’re saying the priorities are,” says Dr. Girgrah. “Make it go down from 30 things on their dashboard to three things. Leaders will always be accountable for 30 different things, but I think our frontline folks need to have things simplified.” The last theme centered around messaging because “there seems to be a desire to have more progress improvement messaging and positive messaging, not just results,” he says. This plays into the competitive value in New Orleans. “Addressing burnout is the right thing to do,” says Dr. Girgrah, adding that “our group practice is our secret sauce and addressing physician well-being gives us a competitive advantage.”

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Incorporating the Mini Z Survey To combat physician burnout, health systems and organizations need to identify stress in its earlier stages and choose programs to prevent burnout . With the 10-item Zero Burnout Program survey, also known as the Mini Z, organizations can identify burnout, stress and potential solutions. The Mini Z survey is short and easy to use, and should be distributed annually. Physicians access the survey online via their computers, smartphones or other devices. Nigel Girgrah, MD, has partnered with the AMA to distribute the Mini Z burnout survey at Ochsner. He plans to use the survey to continue to address the needs of his colleagues— it only took him eight minutes to complete on his smartphone. “I love the fact that it will provide more easily accessible demographic data than the Maslach Burnout Inventory,” Dr. Girgrah says. “It should allow us to benchmark against other organizations and consider departments from Ochsner with two similar departments at other health systems.” Once physicians have completed the burnout survey, the Mini Z data should be shared with practice leaders or office staff. After reviewing the data, it is important to identify the areas of greatest concern— either practice- or organization wide or by department. Based on the problem areas identified, select appropriate interventions to address them.

DESIGNING THE PROPER SOLUTIONS New surveys will be distributed soon, allowing Dr. Girgrah to begin creating and developing solutions to address burnout. Yet, he is getting increasingly impatient because he wants to start implementing interventions to take steps toward an improved workforce. “I’m a pretty analytical person, but honestly, it’s very hard to read a descriptive article about burnout—they all are starting to sound the same. I’m just interested now in moving on to solutions,” says Dr. Girgrah. “I definitely think personal resilience will be important, but I don’t think that’s the first thing we want to offer our providers.” “The heavy lifting is going to be around practice efficiency and there is a thirst to hear what we can do tomorrow to make their lives easier,” he adds. Dr. Hart adds that Ochsner was “concerned about unveiling a program too early since there have been initiatives in the past that never gained any traction. Now that the office has started, we have provided extra communication to them about our timeline.” “The two most important areas to address first are optimization of the electronic medical record and working with our administrative partners to identify and eliminate any tasks that do not provide any value,” Dr. Hart says. “Historically, we’ve been working downstream and being very reactive, working on the coping mechanisms, dealing with crises, but we need to get upstream,” Dr. Girgrah says. “We need to either decrease the frequency or the severity of stressors and increase recovery time or decrease exposure to those stressors where we’re going to acknowledge that there’s always going to be stressors in the work environment.” Another area that is key to success is establishing a connection with physicians and other health care team members at Ochsner. Without their support, the goals will be unattainable—something Dr. Girgrah does not want. For him, that begins with his credibility as a physician and knowing what doctors are going through. If he had to break down his job description, it would be 50% chief wellness officer, 30% medical director and 40% patient care. While he is aware that adds up to 120%, he says he would have a hard time giving up patient care because it brings him so much joy.


“I also fear I would have a credibility issue if I wasn’t seeing patients, so it’d be very hard for me to discuss burnout and discuss the interventions with frontline providers if they didn’t feel that I was in it with them, sort of seeing patients, understanding what it’s like,” adds Dr. Girgrah.

DEFINING RIGHT METRICS FOR SUCCESS “Clearly this isn’t going to be a journey where success is managed and measured in weeks or months. This is a cultural journey over three to five years,” Dr. Girgrah says. “That’s not to diminish that there don’t need to be quick wins, but this isn’t going to be solved by the end of the year.” Executives and doctors at Ochsner are looking for improvements measured through physician engagement and burnout scores assessed by the Mini Z survey, as well as decreased turnover. Since distributing the Mini Z burnout survey in collaboration with the AMA, physicians and advanced practice providers have said it is “much easier to complete than the Maslach burnout inventory that went out two years ago,” says Dr.

Girgrah. “Feedback from our physicians and APPs has been very receptive. “The first day it went live, we heard back that we had the most responses from any health system,” he says. However, in the short term, Dr. Girgrah knows there needs to be action around secondary metrics, such as “work after work.” “I need to show my physicians, as well as my executive team, that we are earnest in our efforts to decrease that work after work,” he says. When looking at the 100 most struggling physicians in Epic out of just under 1,400 doctors, they are spending an average of 90 minutes in the EHR after hours. He is also looking at the data with the APPs. Of course, Dr. Girgrah might not be able to eliminate the after-hours work completely, but he needs to ensure it does not get worse and start shaving off time—whether that is accomplished through Epic badge log-in, pharmacy refills or decreasing in-basket messaging.

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“One thing we are doing immediately is looking at those 100 most struggling physicians and providing them immediate help with Epic retraining and not penalizing them for that,” he explains. “Giving them four hours of customized retraining in Epic and making sure that they’re not being penalized for work being missed in terms of income—that’s priority one.”

They may eventually benefit from that, but what they need in the short term is an hour back to their day and how that is done, that’s the $64,000 question. I’m not diminishing the importance of personal resilience, but I just feel that can’t be what they hear first,” he says. For example, physicians are sometimes asked to attend extracurricular meetings from 5 to 6 p.m. in the evening. To address that this takes away from time at home, Ochsner

The other idea is that those 100 physicians may not be struggling because they are not proficient in the EHR.

One thing we are doing immediately is looking at those 100 most struggling physicians and providing them immediate help with Epic retraining and not penalizing them for that.” — Nigel Girgrah, MD

Instead, it is because even the most proficient doctor might just have too much work. By looking at the data, Dr. Girgrah can see if they can delegate work and why those doctors are spending extra hours after work. Historically the business case around creating efficiency interventions—whether it is giving 30 minutes back to the physician through Epic badge log-in or giving a full 40 minutes back to the doctor by helping with the in-basket— has always been, “OK, how many more patients can they see with that time?” “Now the business case is, ‘Wow, that’s a great thing to do.’ And whether they choose to spend more time with their family, that’s up to the physician,” says Dr. Girgrah. “It’s finding a balance between fixing that work after work and then maybe also still offering some sort of resiliency training or outside sources for that.”

is working on the creation of a program to send those physicians home with a meal, not just for themselves, but for their family. “It sends a message to the family that this organization values your husband’s time, your wife’s time, your father’s time because we asked him to stay an extra hour. Why not put your money where your mouth is and show physicians?” says Dr. Girgrah, adding that “they may sound like not very significant things, but I think these acts do send messages both to the physicians and to their families.” “We are tackling this because it’s an organizational and professional imperative and it’s the right thing to do, not because we’re worried about our economic future or other things,” he says. “We are doing this because it is the humanitarian and compassionate thing that the group practice in an organization does for its physicians.” ■

“The last thing I think a burned-out physician wants to hear is me promoting a yoga class or meditation class right away.

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The power of the kitchen table consult THEIR PATH TOWARD MOVING MEDICINE CONVERGED MORE THAN A DECADE AGO IN THE AMA HOUSE OF DELEGATES. NOW THEIR SHARED PURPOSE STARTS CLOSER TO HOME.

By Brendan Murphy

T

he fight against burnout takes on many forms. Hans and Kavita Arora, a physician couple with a passion for organized medicine, find it works best with a partner on the front lines. Call it a consult or a sidebar, physicians often ask each other for advice. What’s different about when Hans and Kavita Arora are doing it is that it often takes place across the dinner table.

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“If I have a question related to a pregnant patient with a urological issue, I would of course ask Kavita for advice about how she would approach a particular issue in that situation,” says Hans Arora, MD, a urology resident at the Cleveland Clinic. Kavita Arora, MD, MBE, MS, is an ob-gyn at Case Western Reserve University’s MetroHealth Medical Center in Cleveland. She is also married to Hans.

“We can bounce things off each other and decrease the frustration through our shared experience and remind each other of the impact that we have.” —Kavita Arora, MD, MBE, MS

“We are generally involved in the same body region, so there’s a lot of overlap in our fields,” she says. “Even though we’re at different hospitals in different phases of our careers, there’s a lot of discussion and shared terminology.”

FINDING LOVE IN ORGANIZED MEDICINE Kavita and Hans first crossed paths at the 2007 AMA Interim Meeting in Honolulu. A friendship blossomed into a romantic relationship and they dated for four years before getting married in 2011. Though they met at the same stages of medical school, Hans was pursuing an MD/PHD. His extended undergraduate medical education training and their desire to be together once things got serious caused Kavita to transfer residency programs, moving from Philadelphia to Chicago. As Kavita finished residency and Hans completed medical school, they again navigated the geography of their careers in tandem. “That whole process of looking for our next step, there were certainly a lot of compromises,” Hans says. “There were certain places I simply couldn’t rank very highly, whether or not I liked the program, simply because there wasn’t a good job opportunity for Kavita. Similarly, she really had to focus her list on cities in which I had interviews.” This flexibility continues to be a necessary component of making their relationship work. Next year, Hans will leave Cleveland, where Kavita will stay with the couple’s two children. He will spend most of his days training for fellowship in Chicago, returning home on his days off. “What is tricky about compromise in a medical marriage is that a little bit of it is out of your control,” Kavita says. “If it was two of us in practice, so at the same phase of our career, I think it would have been in some ways a little bit more conventional. “I also don’t think it’s a time-limited or one-time thing. I think this is something that all relationships face as careers progress and more and more relationships are dual-career relationships now, compared to the conventional solo breadwinner families.”


LEANING ON EACH OTHER About 40% of physicians are likely to marry another physician or health professional, according to an AMA Insurance Agency Inc. survey of nearly 5,000 doctors. One study found, however, that having a spouse or partner who works as a non-physician health care professional increases the odds of burnout by 23%. Couple that anecdotal evidence with the fact that about half of physicians report at least one symptom of burnout, and there is bound to be some overlap in physician couples and burnout. Generally, physicians experiencing burnout are feeling at least one of three symptoms listed on the Maslach Burnout Inventory—emotional exhaustion, depersonalization and a lost sense of personal accomplishment. As physicians under the age of 55 with children under the age of 21, the Aroras, demographically, are in line for some of the bigger risk factors associated with those experiencing burnout. So, how do they fight burnout? They do it together. “A big part of burnout is feeling frustrated due to a perceived lack of impact,” Kavita says. “Physicians are frustrated about all the administrative hassles, the legislative interference in medicine, or the decline in a patient-physician relationship, you name it, a frustration and a feeling of a lack of impact. And I think we can bounce things off each other and decrease the frustration through our shared experience and remind each other of the impact that we have.”

Kavita Arora, MD, MBE, MS Member since 2005

“In any field that requires not just a time commitment, but an emotional investment in your work, your cup can only be so full.” —Dr. Kavita Arora

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In a practical sense, that means relating to the ups and downs. Those stakes can be particularly high since both are often involved in surgeries where the range of outcomes is vast. “The patient-physician relationship is special, but I think the surgeon-patient relationship is distinct in many ways,” Kavita says. “People trust us with actually hurting them in order to help them, and the stressors at play, as well as what that involves if you’ve had a bad day, are very unique to the surgical fields. Knowing that when someone’s had a bad day in the OR and how that would feel to you, I think is a shared language and a shared understanding that is helpful.” As physicians in demanding specialties, both Hans and Kavita give patients much of their physical and emotional energy. The fact that they understand the nature of working under those conditions is a plus that a non-physician partner may not grasp. “In any field that requires not just a time commitment, but an emotional investment in your work, your cup can only be so full,” Kavita says. “There may at times feel like there’s less of that to go around. In order to be successful, both partners have to be mindful of that situation.”

COMMON PASSIONS The shared experiences the Aroras tout as a benefit of a two-physician marriage are apparent in a number of arenas. Among the most prominent, both husband and wife say, is their collective involvement in advocacy through the AMA. “It’s another way to make an impact that is really meaningful to us,” Kavita says. “We’ve been involved and shared that experience for a long time, and many of our friends and colleagues are involved as well. It’s a nice, nice support system in that regard.” Hans adds “It is great learning what issues the other person finds especially important. Sometimes it is what we would have predicted after more than a decade of involvement in the AMA together, and other times it is not.” Because of the similarity of their specialties, they tend to have many of the same clinical policy interests, working together on AMA policies related to cancer screening and surgery on minors. Outside of their clinical common ground, their perspectives as a

Hans Arora, MD Member since 2005

dual-

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physician couple with children has led them to offer reference committee testimony on issues such as the residency match process and common-sense gun control for safer schools. “We have a shared vision of medicine as occurring not solely in the exam room or operating table, but also in the halls of Congress,” Kavita says. “Working together in the AMA is much more than a shared hobby in that sense. It is not only a shared experience, but a shared community and a shared purpose.”

MAKING FAMILY THE TOP PRIORITY Of course, the couple’s biggest shared passion is for their family. And with demanding schedules, finding quality time can get difficult. “I think it informs the kind of physicians we are and the kind of partners we are to each other,” Hans says. “We’re better physicians because we’re parents, and I think we’re better partners because we’re parents. It’s another shared experience, goal and value system that we have together.” The couple tries to schedule family time—with their children, who are ages 3 and six months—and date nights for each other on a regular basis. The range of activities they try to schedule include playing a board game, watching movies and dining out. They also take a couple of vacations annually. “One of the things about our profession is that there’s always more work to be done and your day doesn’t end when you leave the hospital,” Hans says. “There are always charts to finish, patients to look up, papers to write, books to read.” “In order to make a relationship work between two busy professionals, you really do have to carve out some protected time for yourselves, and prioritize it,” he says. “If you’re going to put so much energy into your work, you have to put that same energy into the relationship, as difficult as that may seem at times.” “For me, my family may not always come first, but they’re the most important thing in my life,” Kavita said. “And that seems counter-intuitive or impossible at first, but in medicine, your patients come first … I might be with a laboring patient or he may be stuck in the operating room, and so you may have to miss things or come home later than expected. It’s helpful to be with somebody who understands that paradox.” ■

“We have a shared vision of medicine as occurring not solely in the exam room or operating table, but also in the halls of Congress.” — Kavita Arora, MD, MBE, MS


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A quest to never waste a step CHRISTINE SINSKY, MD, BRINGS PERSONAL EXPERIENCE AND PRAGMATISM TO THE AMA’S POWERFUL WORK TO TRANSFORM CONTEMPORARY MEDICAL PRACTICE AND PREVENT PHYSICIAN BURNOUT. AND SHE WILL NOT STOP UNTIL HEALTH CARE’S DYSFUNCTION IS DEFUNCT.

By Kevin B. O’Reilly

F

or years, she had trained to get to this time and place. All that Christine Sinsky, MD, had learned and all the technique she had acquired would be rigorously and passionately applied to do better, be faster. She set her sights on the end. Now to make it across the line. Rising out of the waters of Lake Monona in Madison, Wisconsin, after swimming 2.4 miles on a warmer-than-you’dlike September morning, Dr. Sinsky runs to the changing area to start the 112-mile bicycling leg of the grueling, gargantuan Ironman triathlon. Break through that leg and all that remains is the trifling matter of a 26-mile marathon. But something is off.

Christine Sinsky, MD Member since 1985 Photo courtesy American Medical Association

Dr. Sinsky—the 59-year-old internist, the AMA’s vice president of professional satisfaction and one of the nation’s leading lights in the transformation of medical practice to prevent physician burnout—is having trouble seeing out of one eye.

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Are her sunglasses smeared? Is it just a residual artifact of the swimming goggles that Dr. Sinsky had cinched extra tight to keep out water during the swim? No. It is an amigrainous migraine. She gets a few migraines each year, though it has never happened during a race before. With impaired vision, Dr. Sinsky cycles for 75 miles as her arms become increasingly tremulous with fatigue. What do you do when you cannot see the way forward? What is the right way to proceed when you have lost the feeling for the path ahead? Dr. Sinsky, ever attendant to benefits and risks, concludes that it would be imprudent to continue given the course ahead.

Photo courtesy Sinsky family

“Can’t see. Can’t hold the handlebars. Dangerous downhills to come? Better stop,” she says, looking back on the ill-fated 2016 race that is registered with those three ugly letters: DNF—did not finish.

Photo courtesy Sinsky family

But to those who know and admire Dr. Sinsky, it would come as no surprise that the next September she was back in Madison for another go at the Ironman. They will tell you about her exacting zeal—the animating spirit that keeps her looking for new, more efficient and less burdensome means of achieving the desired outcome: to take the next step, to finish the race, to move medicine forward.

All the changes we made in our practice came out of a similar impulse to maximize the enjoyment of the work, and doing work that mattered.” —Christine Sinsky, MD

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MAKING RESIDENCY AND FAMILY A MATCH That is what she has been doing since the days she trained for another awesome task—practicing primary care in the dysfunctional U.S. health system. Dr. Sinsky and her husband, Thomas Sinsky, MD, met in ballroom dance class as undergraduates at the University of Wisconsin-Madison. They fell in love. She was a year ahead of him, and Tom followed Christine to UW’s medical school. Then they landed residency spots in the internal medicine residency program at Gundersen Medical Foundation in La Crosse, Wisconsin. The Sinskys also started their family during residency, and the beginning of their family also marked the start of the Sinskys’ career-long track record of refusing to let their medical vocation impede their calling to raise and be present with their children. As they were both in residency during in the early 1980s, well before duty-hour limits, how could they possibly manage children without having them cared for nearly around the clock by others? Unlike many other resident couples in which the nonphysician partner shoulders the child-rearing and household loads, that wasn’t an option for the Sinskys. It’s said that necessity is the mother of invention. Here, motherhood was the source of the invention. Rather than compromising their family or career goals, the Sinskys proposed an innovative solution to their dilemma to their program director. They would share one residency spot. After the birth of each of their two children—Carolyn, then David—Christine took six months off. Then Tom, in turn, would take time off so that Christine could return for the next block of residency. So that was the idea. But would the program director, a former military physician, go for it? The Sinskys went to him and proposed what Dr. Christine Sinsky describes as “a novel, but workable idea,” and waited for his response. “He did not blink an eye,” Dr. Christine Sinsky says of the man, Col. Edwin Overholt, MD. “He said, ‘No problem. We can do that.’” It turned out, fortuitously, that another couple had made a similar arrangement years prior, but the Sinskys did not know that.

Chris is a very different person. She refused to put up with all the stupid stuff that goes on and results in clinical inefficiency.” —Tom Sinsky, MD

As the Sinskys finished residency within six months of each other, they found their practice home with Medical Associates Clinic in Dubuque, Iowa. The group, which has more than 170 physicians and other advance-practice providers, is Iowa’s oldest multispecialty group practice. The physician-owned group “empowers the physicians to have a certain amount of control over the details of their daily work.” Dr. Christine Sinsky says. So less than a year out of residency, she was on the lookout for better ways of doing things.

THE FIRST TRANSFORMATIVE STEPS “Within that first year, we started getting labs done ahead of the appointment, because we realized that if we had the results we had a more meaningful visit with the patients and less chaos in the practice, and less likelihood of missing an abnormal test result,” Dr. Christine Sinsky says. The move also saves tens of thousands of dollars a year in physician and staff time. Also during those first few years in practice, Dr. Sinsky implemented the idea “to renew all the patients’ stable chronic illness medications at the annual appointment.” The flexibility within Medical Associates Clinic allowed her to experiment with that. The change was made within the Sinsky practice

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“as opposed to having to get every physician in the department or every physician in the clinic to agree to do a process the same,” Dr. Christine Sinsky says. This and many other of Dr. Christine Sinsky’s efforts would become the core of the AMA STEPS Forward™ collection of open-access CME modules that offer innovative strategies allowing physicians and their staff to thrive in the new health care environment (see callout below). When most time-squeezed primary care physicians struggle to tread water amid the increasing bureaucratization of practice, Dr. Sinsky took the initiative to find practical ways that met the quadruple aim of better patient experience, better population health and lower overall costs with improved professional satisfaction.

“I just didn’t know any better,” she says. “Maybe I’m just optimistic that you can always make things better.” Dr. Tom Sinsky agrees, noting: “My wife’s an incredibly efficient person. She has the mind of an engineer. She hates to see any moment wasted.” Yet the clarion call of family also was a major factor. “We had two young children, and we were both tied to medical practice, taking call, doing clinic and working weekends, so we were up against the wall,” he says. “Someone has to cook dinner. We couldn’t spend the extra two to three hours in the office and get work done.”

Redesigning practice—step by step The AMA STEPS Forward™ collection of practice improvement strategies offer expert-driven guidance that allow physicians and their staff to successfully implement meaningful and transformative change in their practice. The modules can help prevent physician burnout, create the Organizational Foundation for Joy in Medicine™, create a strong team culture and improve practice efficiency. The modules below are example of modules written by Dr. Sinksy and our STEPS Forward physician faculty: WORKFLOW AND PROCESS

“Pre-Visit Laboratory Testing: Save Time and Improve Care.” TREATMENT ADHERENCE

“Annual Prescription Renewal: Save Time and Improve Medication Adherence.” WORKFLOW AND PROCESS

“Expanded Rooming and Discharge Protocols: Streamline Your Patient Visit Workflow.” WORKFLOW AND PROCESS

“ EHR In-Basket Restructuring for Improved Efficiency: Efficiently manage your in-basket to provide better, more timely patient care.” WORKFLOW AND PROCESS

“Team Documentation: Improve Efficiency, Workflow, and Patient Care.”

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WORK THAT MATTERS Dr. Christine Sinsky remembers the glorious fall colors in 1994, seven years after the Sinsky practice came into being. The leaves had turned rusty red, with little yellow underbellies. And then, turning away from her office’s wall-to-wall window with a view of the Mississippi River, she felt trapped. There would be no romps in the leaves with the children while the sun hung in the sky. She still had a stack of charts to go trudge through, and that would take at least another hour. “If I’m going to stay in practice, I have to do something differently,” she thought to herself. “I have just become a documentation drone.” It was around this time that in their practice the Sinskys “started to systematize all the standardized, predictable work of the practice and shared work with the nursing staff,” she says. “So the nurses could be the ones to close all the care gaps. They could be the ones who gave all the immunizations during rooming, as opposed to waiting for me to remember that—among all the other things going on with the patient. “All the changes we made in our practice came out of a similar impulse to maximize the enjoyment of the work, and doing work that mattered, and work that the nonphysicians on our team could not do,” Dr. Christine Sinsky says. Dr. Tom Sinsky puts a different spin on the practice transformation at play. He imagines many primary care physicians—including himself, to a certain degree—as akin to soldiers fighting in trench warfare. “Never put your head up, try to get through and get home,” he says. Dr. Christine Sinsky has the wherewithal to “look up, look past the snipers and say, ‘This doesn’t make any sense. We’ve got to change this,’” he says. She “could somehow get this view from the top, looking down from some observation point to see these dysfunctional systems and patterns.” He notes, in particular, the impact of expanding the nurseto-physician ratio (5-to-2) in the practice and giving nurses an expanded role in rooming patients, carrying out standing orders and taking charge of tasks such as EHR data entry and medication reconciliation. “We spend quality time with the patient,” Dr. Tom Sinsky says of the physician’s role in the Sinsky practice. “I don’t take the computer in the room. My nurse has a computer.”

Deb Althaus joined the Sinsky practice in 1997 and served as the primary nurse until Dr. Tom Sinsky retired from practice earlier this year. At that time, Dr. Christine Sinsky also decided to retire from clinical practice to spend 100% of her working time in her VP role at the AMA. “As we transitioned to team-based care, they called me the quarterback of the team,” Althaus says. She would triage incoming phone calls from patients, pharmacies, other clinics and other offices. As much of this communication became centered in electronic systems, Dr. Christine Sinsky worked with Althaus and the other nurses on staff to better manage the EHR in-basket. “We had protocols that we’d work under and we set guidelines” on matters such as abnormal laboratory values, Althaus says. She estimates that of the 50 to 100 EHR inbox messages that came in daily, only about 10% needed Dr. Sinsky’s attention.

DEPARTING FROM DUBUQUE Word started to spread within Medical Associates Clinic about the practice transformation afoot in the Sinsky practice, says Brian Sullivan, MD, chair of the group’s internal medicine department. “When other physicians would get frustrated with certain facets of their practice, they’d say, ‘How are Tom and Chris dealing with it? Because they’ve probably already figured it out,’” Dr. Sullivan says. “They’ve been tremendously giving and open with sharing their ideas,” he adds, noting that the Sinskys played an influential role within months of his arrival at Medical Associates Clinic from residency. “It’s hard to overstate their impact because it’s been there since I first came here 20 years ago. Even when I started really making customized adjustments to my practice, it was all influenced by what they were doing.” But Dr. Sinsky thought these transformative ideas should go beyond Dubuque. She began taking on speaking engagements at medical conferences to talk about the improvements that she, Tom and the rest of the team had accomplished together. She also started working with mentors such as University of California, San Francisco Family Medicine Professor Thomas Bodenheimer, MD, MPH, American Board of Internal Medicine Foundation President and CEO

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When other physicians would get frustrated with certain facets of their practice, they’d say, ‘How are Tom and Chris dealing with it? Because they’ve probably already figured it out.’” —Brian Sullivan, MD

Photo courtesy Getty Images

Richard J. Baron, MD, and Harvard Associate Professor of Medicine John D. Goodson, MD.

and measurement surrounding the efficacy of practice interventions.

A recent search of the National Library of Medicine’s website reveals that Dr. Sinsky has written or co-written more than 50 peer-reviewed medical journal articles, often in high-impact outlets that reach broad swaths of practicing physicians and physician influencers.

Last year, the AMA piloted its work in this area, which includes customized surveys that can help organizational leaders set priorities for changes that can have the most impact on the quality of physicians’ working lives. In 2019, Tutty says, the AMA has repeat customers and is looking to quadruple the number of health systems the Association works with.

Michael Tutty, PhD, brought Dr. Sinsky to the AMA, where he is group vice president of physician satisfaction and practice sustainability. “Chris Sinsky has become one of the foremost experts in the areas of physician dissatisfaction, physician burnout and joy in medicine,” Tutty says. “There are a lot of people talking about these issues and selling themselves on it for a profit. What we do here at the AMA has academic rigor, and Chris took this role because she really believes in the work, and that this was a platform at the AMA to make a difference in physicians’ lives. It’s not just lip service.” Aside from her essential role in bringing the influential STEPS Forward modules to fruition, and her writing and speaking engagements, Dr. Sinsky oversees the AMA’s work on organizational assessment of physician burnout

The STEPS Forward modules are replete with case studies of how the ideas that Dr. Sinsky put into place in Dubuque have affected physicians, health professionals and patients around the country. To take just one example, six months after an AMA visit to Crusader Health in Rockford, Illinois, that focused on synchronized prescription renewal, a physician assistant reported that “he was saving about 30 minutes a day, his inbox was empty by the end of the day and he was leaving work on time.” Over the course of a year, that adds up to two solid weeks in time saved. In total, the nonprofit with 70 physicians and other clinicians will save hundreds of hours of clinician time each month. Hours are precious. They can be spent following the fall colors, enjoying a home-cooked meal with family, cutting up the dance floor with the love of your life—or training for a triathlon.

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THE IRONWOMAN ARRIVES It’s another warm September day in Madison for the Ironman event, a year since Dr. Christine Sinsky was forced off her bike by a migraine and arm fatigue. Naturally, she returned to training with new handlebars for her bicycle to address the arm fatigue that helped push her out 365 days earlier. The so-called aerobars serve as arm rests, cantilevering out over the front wheel, allowing Dr. Sinsky to cut the pressure on her hands and wrists. The migraine does not recur. Dr. Sinsky completes the swim and the bike portions of the competition. Yet even with 23 miles of the marathon behind her, she still is not certain she can make it to the finish. But she does not waste a stride. She sets one foot in front of the other and soon enough she is in sight of the Wisconsin State Capitol and the finish line, a mere 15 hours and 30-odd minutes after she started slicing her arms through the water of Lake Monona. Her finish time will be good enough to give Dr. Sinsky fourth place in her age group. Atop the capitol dome, nearly 285 feet above the pavement Dr. Sinsky pounds with each step, is a 15-foot gilded statue. This female figure, draped in robes and clutching a globe, was constructed as an allegory of devotion to progress. The figure’s arm is held aloft, offering an encouraging wave toward a future filled with transformative advancement. The statue is named “Wisconsin,” but the folks around Madison have come up with their own term of endearment for this bold woman with skyline vision.

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Photo by Justin Ormont, changes made in accord with license

They call her “Lady Forward.” ■


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Well-being 101: Elevate the conversation AT THE UNIVERSITY OF NEBRASKA MEDICAL CENTER, STUDENTS LEARN THE IMPORTANCE OF RECOGNIZING ONE’S LIMITS, BUT MORE IMPORTANTLY, NOT TO FEAR TALKING ABOUT IT.

By Tanya Albert Henry

U

niversity of Nebraska Medical Center (UNMC) Chancellor Jeffrey P. Gold, MD’s, spring graduation speech briefly acknowledged the wisdom and skills medical students gained. It made mention of the longterm achievements that await. But the final message to students was one about the importance of guarding their own well-being. Not forgetting the stamina, perseverance and tenacity that propelled them through the tough times on their path to graduation day. Dr. Gold told the future physicians just how essential those resiliency skills would be in their careers, as each of them will confront failure and times of doubt at some point.

“We cannot give full dedication to healing as we have sworn an oath to do if we ourselves are not truly resilient, if we are hurting, if we no longer have the very best of ourselves to give to others,” Dr. Gold told the newest MDs. “We have recognized this here at UNMC. This is why we have made mental health wellness and stress management one of our greatest emphases, a set of foundational principles.” Sending UNMC graduates off with a reminder that their own mental health is paramount is just one way physician wellness is an increasing part of the culture at UNMC. It’s an example of how UNMC leaders are toppling the stigma and barriers that have for so long stopped physicians from seeking help when they need it most. The journey to change the status quo started about five years ago when news of internal medicine trainees’ suicides jolted Dr. Gold, a past chair of the AMA’s Council on Medical Education.

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Photo courtesy UNMC

He was part of the conversations taking place at the Accreditation Council for Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) about the learning environment where future physicians are trained.

was about changing the culture for students, physicians intraining, practicing physicians and staff. It was about finding better ways for physicians and other health care professionals to function in their day-to-day responsibilities. It was about providing physicians with the resources they need.

He had read study after study coming out about physician burnout. He had personally seen the administrative burdens that electronic health records were putting on practicing physicians. And he had seen the stress that was added to the profession as the nation’s health care payment system was in flux while the Affordable Care Act went into effect.

He convened a taskforce whose goal was to understand the strains on students and faculty at the medical and health science schools that comprise UNMC and to understand what was going on with Nebraska Medicine’s physicians, nurses and staff that provide patient care.

Dr. Gold—at the helm of seven colleges, overseeing staff and faculty of about 5,000 and the school’s 3,800 students, as well as Nebraska Medicine’s more than 6,500 employees—knew something needed to change at the organizational level. This wasn’t about just adding a stress-management class or bringing in a speaker to talk about taking care of yourself. This

Out of that effort came a multi-pronged approach that makes well-being and resiliency part of the conversation at every level and in every corner of UNMC campuses and Nebraska Medicine’s health care centers. Mental health resources continue to become more easily accessible and even in the palm of student, faculty and staffs’ hands through smartphone apps.

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People are reluctant to come forward because of the career impact they fear it will have” —Jeffrey P. Gold, MD

And in February 2018, Dr. Gold named Steven P. Wengel, MD, who had chaired UNMC’s Department of Psychiatry for more than a decade, to a newly created position: assistant vice chancellor for campus wellness for UNMC and the University of Nebraska at Omaha. His job, in part, is to investigate and implement the best practices to enhance student, faculty, staff and patient wellness. That includes assessing stress and burnout levels, developing new curricula for trainees, organizing workshops on stress management and promoting environmental changes that improve well-being.

So, Dr. Gold is trying to change that on the organizational and individual level by talking about it. A lot. It is the thrust of his graduation speech, and a part of the conversation just about everywhere he goes. He’s encouraging others to talk about it at the faculty level, the administrative level and the student level. A big part of elevating the conversation is inviting people to talk about wellness and bringing in experts to help foster the discussion. UNMC in February hosted its 4th Annual Elevating the Conversation event, a symposium about health professionals’ well-being. This year Nancy Nankivil, the AMA’s director of professional satisfaction and practice sustainability was the keynote speaker for the day where physicians and other health professionals explored factors that hinder or build organizational well-being. “When people are burned out, they may be the last person to see it,” Dr. Gold says. “We are promoting a see something, say something environment: If you see a colleague who does not seem themselves, say something. You may not get the response you want, but just say you are concerned. It could make a difference.”

PROVIDING THE NEEDED RESOURCES Wellness has even been incorporated into UNMC’s strategic plan and has its own scorecard to ensure goals are being met and to ensure that it continues to permeate all aspects of the organization. “There is a limit to how many activities an organization can focus on. But this is not a flavor of the month. It is not a box we check off. This is ongoing,” Dr. Gold says. “We’ve started to do the deep dive into what is causing this problem and finding ways to make changes.”

GET RID OF STIGMA Perhaps one of the most fundamental things that needs to change is eliminating the stigma attached to seeking mental health care and the worries physicians face if they come forward saying they need help. “People are reluctant to come forward because of the career impact they fear it will have,” says Dr. Gold. “We have been afraid to talk about it on an organizational level. And there is a fear on the individual level that if we talk about it, that we are somehow weak.”

Beyond making people more aware and open to talking about challenges they may be facing, UNMC is putting resources in place to connect physicians with the help they need. UNMC has a number of smartphone apps for students, faculty and staff to download. One app asks the person how they are doing and is an assessment tool for well-being. If needed, the app will prompt you to talk to someone. There are phone numbers and other resources built into the app to connect users with the right professionals. UNMC has an Employee Assistant Program (EAP), a voluntary work-based program that offers free and confidential assessments, short-term counseling, referrals and follow-up services for personal and work-related problems. It offers a student counseling center that is discreet and gets students in for an appointment quickly. There also is a less formal student wellness advocate who has an office where students can drop in for a cup of coffee

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If you see a colleague who does not seem themselves, say something. You may not get the response you want, but just say you are concerned.� Jeffrey P. Gold, MD Member since 1977

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There also is scientific data now that shows that the more exposure a medical student has to the humanities, the less burnout he or she felt.” —Stephen P. Wengel, MD

and chat about what is on their mind. For some students, Dr. Wengel says, that may be all they need. For those who need more, the wellness advocate can link them with the right resources. And UNMC makes everyone aware of the Metro Omaha Medical Society’s (MOMS) online assessment tool physicians can use to determine if they need help. In addition to helping physicians find help, MOMS links physicians with peers to share their challenges and start thoughtful conversations. “You will never be able to prevent all mental health issues. Depression and anxiety are always going to be there. It’s about having the resources there to help people,” Dr. Wengel says. “We are trying to have as many resources available as possible.”

CONNECTING WITH OTHERS A geriatric psychiatrist since 1991, Dr. Wengel has studied and seen the importance meditation and stress management play in the health and well-being of his patients. He writes prescriptions for patients to practice meditation at home. He also practices meditation himself. About four years ago, he began teaching a class at UNMC to help doctors in-training better manage their stress. It was popular from day one. And it was not just popular with senior medical students who were interested in psychiatry, but also

with those looking to go into primary care, anesthesiology and other specialties who wanted to be good coaches in helping patients manage stress and who wanted to learn how to better manage their own stress. To build resiliency in other ways, Dr. Wengel is helping create opportunities for students and faculty to interact with or partake in the different branches of the humanities. “We organically know it is good to have a life outside of medicine, but there also is scientific data now that shows that the more exposure a medical student has to the humanities, the less burnout he or she felt,” Dr. Wengel says. In addition to showing that medical students exposed to the humanities were less likely to report burnout, the study found that the exposure led to higher tolerance of ambiguity and empathy. That increase in the tolerance for ambiguity “is good for doctors because patients come in and not always present the way physicians were taught in the textbook,” Dr. Wengel says. One way UNMC and Nebraska Medicine is giving its faculty, staff and students a chance to take part in the humanities is through a campus orchestra formed in the Summer of 2018. UNMC’s Department of Neurological Science Chair Matt Rizzo, MD, a cellist who saw an orchestra contribute to the morale at the University of Iowa, approached Dr. Wengel about forming the orchestra as an outlet for professionals in Nebraska. Dr. Wengel helped forge a partnership with University of Nebraska Omaha School of Music director Washington Garcia and now about 50 people from UNMC and Nebraska Medicine are part of the Nebraska Medical Orchestra. The group’s composition is about 50% students, 20% faculty and 30% staff or others tied to UNMC or Nebraska Medicine. Their first concert was Dec. 5 and they held a second one this spring. Anecdotally, Dr. Wengel says, they know the program is having a positive impact. The musicians have said it is a stress reliever and has allowed orchestra members to forge friendships outside of the classroom or workplace. A wellness survey is underway to more formally assess the program’s impact. After the orchestra formed, a third-year medical school student approached Dr. Wengel about creating a UNMC acapella group. The “Doc’Apella” group has done a number of performances for hospitalized patients and also sang at a recent memorial service for families who have donated loved ones’ bodies for medical students to study.

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Photo courtesy UNMC

Another creative outlet for students that helps their own wellbeing and their future patients’ well-being is culinary school. Fourth year medical students have the opportunity to take a class at the Metropolitan Community College’s Institute for the Culinary Arts. Students spend time learning about the science behind the benefits of the Mediterranean Diet and then get to take hands-on cooking classes at the culinary school, learning how to prepare healthy meals and increasing their confidence in counseling on nutrition.

SOLVING UNDERLYING PROBLEMS While teaching resiliency is an important piece, so too is changing the system-issues in medicine that are causing physician burnout in the first place. UNMC and Nebraska Medicine are working to streamline their bureaucracy and they are also looking for ways to improve electronic health records. It’s well-documented that electronic health records are a big

contributor to the stress that physicians feel today. Doctors are trying to catch up at 10 p.m. and on the weekend, disrupting their work-life balance. Dr. Gold said they are searching for ways to make the process more efficient. For example, he noted that computers being able to listen to conversations may be one way to reduce the time physicians spend on the task.

NEVER DECLARING VICTORY While UNMC has made great strides in making wellness an integral part of campus life, Drs. Gold and Wengel say their work is far from over. Wellness needs to be a continuous part of the conversation, Dr. Gold says. To see what in-roads they have made and determine what needs must still be met, UNMC students, faculty and staff recently completed a wellness survey. It asked people to rate how much they believe their personal wellness is valued at UNMC, to gauge their level of burnout, if any, and to tell administrators if they believe they have access mental health supports if necessary.

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Photo courtesy of the UNMC

“We are looking to it for direction,” Dr. Gold says. “This journey will require changes.” Forging this path and making wellness such a large part of campus life provides people hope that things are moving in the right direction, Dr. Wengel says. “At their heart, physicians love taking care of patients. It’s exciting and fulfilling, yet other obligations in medicine have distracted from what attracted physicians to medicine,” he says, while noting, that the wellness movement “is bringing back the joy in medicine.”

“You must realize that sometimes the surest indication of individual strength and your true resiliency is the willingness to depend upon others in order to get the job done and to maintain your stamina and your perseverance,” Dr. Gold told the 2019 graduates. “And so, just as we prepare our students and residents for untold clinical complexities and high-risk and life-altering clinical care, we also have worked to prepare you to handle stress, to stave off burnout, to build resiliency and to know when and how to depend upon others and when to ask for help.” That is a lesson those at UNMC will continue to pursue relentlessly, no matter how much progress they’ve made. ■

As Dr. Gold sent the spring graduates off to the next stage of their careers this year, he reminded them that at some point in their journey it will be important for them to think back upon the excitement they brought with them to medical school. To go back and read the personal essays they wrote about why they wanted to come to medical school.

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AFTER YEARS OF LEADING EFFORTS TO UNDERSTAND THE MAGNITUDE OF THE BURNOUT EPIDEMIC, RESEARCHERS LOTTE N. DYRBYE, MD, MHPE, AND COLIN P. WEST, MD, PHD, LOOK TO THE NEXT CHALLENGE: QUANTIFYING THE IMPACT OF SOLUTIONS.

By Timothy M. Smith

I

n the summer of 2012, the U.S. medical community still hadn’t experienced its collective “aha!” moment in understanding the prevalence of physician burnout.

Lotte N. Dyrbye, MD, MHPE Member since 2012

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“People would ask me, ‘Why are you studying this? Do doctors really have it worse than anyone else?” says Lotte N. Dyrbye, MD, MHPE, professor of medicine and medical education at the Mayo Clinic Alix School of Medicine and one of the relatively few researchers looking into the phenomenon at the time. “There wasn't a good sense nationally of whether this was a problem for the profession or just a niche issue affecting a handful of less-well-adapted physicians or learners.” That moment would come in August with the publication, in JAMA Internal Medicine, of a study by Dr. Dyrbye and others at Mayo Clinic comparing burnout among U.S. physicians with the general population. There was already lots of data on physician burnout, but this was the first national study. It concluded that burnout was, in fact, more common among physicians than among other workers and that doctors working in specialties at the front line of access seemed to be at greatest risk.

>

45%

of the physicians surveyed found burnout symptoms to be present

“After many years of feeling like we were running uphill, trying to understand whether this was a real issue, suddenly, seemingly overnight, we were getting very different questions, like, ‘How do we fix this?’” Dr. Dyrbye recalls. Since then, most interventions aimed at curbing burnout have been directed at individuals. This has given rise to an array of time-management and self-care techniques, as well as corresponding data on their effectiveness. But while resilience is an important bulwark against burnout, it is sometimes overemphasized in organizational efforts, leaving physicians and medical students with the feeling that no one is looking out for them. “The message they’re getting seems to be, ‘You just need to be stronger to deal with your working environment. You’re not committing yourself to those individual strategies sufficiently,’” says Colin P. West, MD, PhD, professor of medicine, medical education and biostatistics at Mayo Clinic Alix School of Medicine and co-author of the 2012 study.

People would ask me, ‘Why are you studying this? Do doctors really have it worse than anyone else?’” —Lotte N. Dyrbye, MD, MHPE


The medical community has needed a second revelation, Dr. West says: that individual-directed measures are simply a first step. The real solution to burnout is changing the working and learning environments at academic and community medical centers. The good news, for starters, is that every major accrediting and licensing organization in the United States has now meaningfully endorsed the need for culture change. “System and organizational change are huge boulders, though, and the science is very hard,” Dr. West says. “There have been a number of efforts to try to move the organizational levers, but I don't think they are as visible to people outside of the research world because the outcomes from those interventions have been harder to come by. What I think will help people feel more comfortable that this effort is going in the right direction is to see that organizational science around culture change and system change. Again, those are really big boulders, and it’s slow going to get them started in a different direction. But the people who are going to be able to effect those changes, their ears are open and they’re engaged.”

BROADER VIEW OF BURNOUT’S IMPACT Since 2003, Drs. Dyrbye and West have been working on longitudinal studies looking at quality of life, burnout, empathy and other markers of personal well-being among medical students and internal medicine residents. Dr. Dyrbye, who immigrated from Denmark when she was 5 and learned English largely from watching the TV medical drama “Emergency!” had been a practicing physician, but was inspired to go into research after hearing pioneering investigator Tait D. Shanafelt, MD, present a study on burnout in University of Washington residents and how it related to suboptimal patient care practices. Dr. West, who notes that he had never heard the term “physician burnout” before he became Mayo Clinic’s chief internal medicine resident, was asked to join the research team because of his background in biostatistics. Today, Drs. Dyrbye and West co-direct Mayo Clinic’s Program on Physician Well-Being. As big an issue as physician burnout has become, there still aren’t many researchers studying what drives it or what works to fix it. This is mostly a function of the scant research dollars available. Drs. Dyrbye and West are considered by many to

The case could be made more strongly for incorporating wellbeing research into other investigations.” —Colin P. West, MD, PhD

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Colin P. West, MD, PhD Member since 1993

Photo courtesy Mayo Clinic

be among the Beatles of burnout research, in part because of their persistence in getting studies done on shoestring budgets. But this lack of funding may also be due to a failure of imagination. One key to accessing resources, they note, is taking a broader view of the topic of physician well-being. Some researchers may not yet appreciate how it relates to topics they are investigating. “We as researchers have to take some responsibility. The case could be made more strongly and in a more appealing fashion for incorporating well-being research into other investigations,” Dr. West says. “If you’re studying a clinical outcome, and if we've got strong evidence that physician well-being is a driver of clinical outcomes, then it makes sense to incorporate physician well-being when the overall goal of the grant is to go after improving care. Similarly, burnout researchers need to be reaching out for partnerships with investigators who have other successful lines of funding, to look for areas where there could be mutual benefit.” Given that medical research is most commonly funded

by large government agencies, work also needs to be done to help the general public and politicians understand the implications of physician well-being on quality and cost of care. “What you don't want is to send the message that you have a bunch of overpaid doctors whining that their jobs are hard,” Dr. Dyrbye says. “Physicians expect and want to work hard, but they need to do so in efficient systems that support, rather than hinder, their efforts.” She suggests bringing the conversation back to the triple aim: lower costs, improved quality, better access. These all rely on a healthy professional workforce, and that means solving burnout. “There are probably some chief financial officers who still need convincing too,” Dr. Dyrbye says. “It's easy to say that if you increase the number of patients a physician sees, revenue's going to go up. But that's a huge assumption because ultimately if you burn out that doctor, quality of care is going to go down, cost of care is going to go up, and that physician will be more likely to cut back on hours or leave, which

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could cost you a lot of money. If there are medical errors or malpractice suits, those also could cost you a lot of money. So, you might do better financially if you change the work expectations of your physicians and invest in other members of the health care team and practice-improvement initiatives.”

Physicians want to work hard but they need to do so in efficient systems that support their efforts.” —Lotte N. Dyrbye, MD, MHPE

Being at this new frontier of awareness also means the medical community is now in a better position to contemplate the fullness of the burnout experience, including the impact of bullying, discrimination and the hidden curriculum. Harassment, for example, is known to drive depression and burnout in medical students, but not much is known about how it affects physicians in practice. Moreover, the effectiveness of a burnout solution could be impacted if it is implemented in an environment struggling with systemic biases. The drivers of burnout may transcend the practice and organizational environments too, so identifying them requires novel measurements. For example, how do payment models and financial incentives affect physician well-being? What about malpractice liability and tort reform? How do performance feedback reports to physicians affect their well-being? “There also hasn't been much work in the U.S. looking at how to help people recover from burnout,” Dr. Dyrbye says. “What is the natural course of it? How many people recover on their own? What kind of strategies facilitate more expedited recovery, other than cutting back on work hours? Is there an optimal return to work process, so to speak?”

WHERE ANSWERS LIE Despite the many questions facing researchers, some answers are readily available at the organization level. For example, most organizations have quality improvement activities aimed at a wide variety of outcomes, from improving diabetes control measures to reducing length of stay. “There are a ton of these going on all the time. We implement process changes and then measure outcomes,” Dr. Dyrbye says. “What we fail to do is measure the impact on the workforce. How did it affect their cognitive load or their clerical burden? Did it change their connection to colleagues? Are they now more isolated? Do they get more or less meaning in work? Did it increase or decrease flexibility and autonomy?”

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The electronic health record, despite its notorious role in driving burnout, is also a place to look for answers. Imagine, for example, if 60% of physicians’ orders are teed up in gastroenterology, but only 20% are teed up in pulmonary. Such a disparity could point to areas where care teams could be operating more efficiently, giving physicians more time to work at the top of their licenses, but much of this data is not yet mined. Many organizations simply don’t know how differences in their staffing by practice and workflows may be contributing to burnout. System-level change isn’t unprecedented, by the way. A 1999 report from the U.S. Institute of Medicine (IOM), “To Err Is Human: Building a Safer Health System,” initiated sweeping changes to the health care system to improve quality and patient safety. “Rather than getting paralyzed by, ‘Oh my goodness, how do we change culture?’ we can go back to what we learned from that process over the last two decades,” Dr. West says. “How can we implement analogous strategies for well-being? And ideally, how can we learn from areas where the safety and quality missions have hit bumps in the road so that we can steer around those and make progress even more quickly than the safety and quality efforts have been able to achieve?” If you go back to the years before the IOM report, Dr. West notes, few health care organizations had a patient safety officer or a formal focus on quality outcomes. Safety and quality had always been important in a general sense, but they weren’t formalized in the structure of a health care organization. The IOM report changed that, and now every organization has a safety and quality officer. “Something that the IOM report made so evident was that our approach to fixing errors in our health care system required us to acknowledge that our system needed to change to promote safety,” he says.


“I think the analogy is quite clear when we talk about wellbeing issues: The system is what needs to change so we can promote thriving and well-being for our health care professionals.”

A CHARTER FOR THE PROFESSION It’s easy to get caught up in the blitz of burnout statistics— which specialties are hit the hardest, which ones the least, whether the overall percentage of affected physicians is ticking up or down—and those numbers do count, after all. But such a narrow view could lead one to think that little has changed in the last seven years, when, really, the environment is altogether different simply for the medical community’s awareness of the issue and its commitment at the highest levels to solving it. Last year, JAMA published the “Charter on Physician Well-Being,” a document conceived during a meeting shortly before of leaders from organizations spanning the medical profession at the Accreditation Council of Graduate Medical Education’s headquarters, in Chicago. Dr. West attended from Mayo Clinic. “In informal conversations, almost everyone agrees that we need to promote well-being—it’s good for everybody—but how do you systematize that?” Dr. West says. “The idea of the meeting was to come together around a framework of expectations for the entire profession.”

Based loosely on the Physician Charter developed by the ABIM Foundation in 2002—which identified the primacy of patient welfare, patient autonomy and social justice—this charter features four guiding principles and eight key commitments focused on well-being. “It does acknowledge that we have an individual responsibility as physicians for self-care, but that is housed among seven other commitments that go up the ladder of responsibility from local leadership to the health care system as a whole,” Dr. West says. The hope is that the charter will serve as a reference point around well-being issues for practices, organizations and policymakers when implementing reforms—including when, say, the AMA is in conversations with the Centers for Medicare and Medicaid Services about payment models, or when the American Association of Medical Colleges is working with medical schools on redesigning learning environments. “I think the most compelling piece of all of that for me was how resonant the content was. We got about 25 thought leaders together, and in a day and a half, they came to consensus,” Dr. West says. “That was remarkable, and it speaks to how together we are as a profession around these issues.” ■

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End note

Six digital destinations that you shouldn’t miss.

1

“If you care about human beings… then you care about whether physicians and other clinicians have the opportunity for joy in work.” That commentary comes from Christine Sinsky, MD, the AMA’s vice president of professional satisfaction on the Inside Angle podcast episode “Physician burnout: How can we improve the work of care?” with host L. Gordon Moore, MD.

3

Whether you’re experiencing burnout symptoms or just want to learn more about this significant issue, the AMA’s Burnout Tip-of-the-Week email series is for you. Sign up to receive exclusive insights, tips and resources to manage burnout and improve professional satisfaction.

5

The Moving Medicine podcast episode “Physician Well-being, part 3: Developing a culture of wellness” offers insights from John P. Fogarty, MD, dean of the Florida State University College of Medicine (FSU). In it, Dr. Fogarty discusses the outpouring of grief following an FSU medical student’s suicide and outlines the FSU Wellness Committee’s efforts to create a culture that promotes wellness for students. The episode is one of three in a series on physician well-being.

2

In corporate medicine’s ongoing quest for ever greater efficiency, “the professional ethic of medical staff members” are often viewed as a renewable resource. Bellevue Hospital physician Danielle Ofri, MD, PhD, shares her thoughts on the pressure placed on medical professionals to “suck it up” in the face of mushrooming workloads in the The New York Times opinion piece, “The Business of Health Care Depends on Exploiting Doctors and Nurses.”

4

The AMA’s Physician Burnout page features all the Association’s latest burnout articles. New stories every month cover a variety of burnout-related topics, including burnout rates across different specialties, how physician moms can achieve work-life balance, personal factors signaling your risk for burnout and much, much more.

6

The conversation around physician burnout isn’t entirely bleak. A Mayo Clinic Proceedings article highlights a study concluding that burnout and satisfaction with work-life integration among U.S. physicians improved between 2014 and 2017. The study also determined there’s plenty room for improvement for physicians compared to workers in other fields.

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48 | AMA Moving Medicine Magazine | Summer 2019

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Moving Medicine | Summer 2019 - Staff Edition  

Moving Medicine | Summer 2019 - Staff Edition  

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