Physician Burnout & Well-Being

(group murmuring) (group murmuring) – You can keep talking, we’ll
wait another minute or two. Well, I tell you what, let’s
go ahead and get started. I think we have a online
following, as well. So, first, thank you for
taking the time to come today. As you may know, this week
is Patient Experience Week, and the team has been
working on patient experience thought well it’d be a good
thing to also talk about clinician and physician experience, and that’s our topic today. So, welcome to this
first Physician Burnout and Well-Being Panel. I think this is one of many
activities going on this week, and I’m sure it will be a topic
that we’ll be thinking about quite a lot in the coming weeks, months, and years. I don’t think anybody who’s in this room is surprised to hear
about physician burnout. I think, perhaps like
myself, or perhaps not, I was surprised at how broad it is. Surveys done here, and
surveys done elsewhere show that this is really an issue that is of major concern for
us and many of our colleagues; It has all kinds of implications as the implication that that as a result that you’re not enjoying your passions as much as you might be because of the factors that
are involved in burnout. It is associated with
increased medical errors, with decreased empathy for patients, with staff turnover,
with physician turnover. I think that it’s an issue
that is one that we, I hope, can address, and address seriously, make changes so that we can
find ways in which we can minimize a way that
today’s events affect us. I want to be quick to state that this is not a physician problem. I think it certainly
is a clinician problem, but I was meeting this
morning with managers, some of our leadership
group, and they feel it. I think everyone feels it,
and I think it’s a result of many, many different pressures
that we have in our life. Pace, responsibilities,
one of them mentioned, made a comment that they always
feel tethered to their work, and I’m sure that’s true for every single person in this room, and that just doesn’t allow them to feel away from it, and relax. So we have a wonderful panel
who’s agreed to be here today. I’ll give them brief introductions, and then they’ll briefly
explain their role in our efforts to reduce and
prevent physician burnout. Then I have a couple of questions that I’ll use just to kick off, but what we’d really like to do is have the panel address
questions from you. So, Kirk Brower is right
down there at the end. Kirk is a professor of psychiatry and director of the
Michigan Medicine Faculty and Physician Health Initiative. Rob Ernst is here in the middle. Rob is associate professor
in the Department of Internal Medicine and
senior associate chief for ambulatory care. Margaret Dobson, there, is the family medicine
residency program director. Kelly Orringer is the
division chief and director for general pediatrics. And Srijan Sen is associate
professor in psychiatry. I will mention Kelly and
Rob are both involved in some pilots that we’re going to, we’re working on getting initiated, one in general medicine and
one in general pediatrics. So, to kick of the discussion, let me just ask a question. I’ll direct this, because I had a sheet that says where to direct it. So, I’ll direct this first
question to Kirk and Rob. What is happening at a national
level involving burnout, and why do you think we’re
hearing more about burnout today than we ever have before? – Well, I think we’re
hearing more about it. There was a influential
article that came out in 2014 that showed about one half of physicians had frequent symptoms of burnout, and that was picked up
by the national press, as well as some of our organized
medicine organizations, including the A-M-A, the A-C-G-M-E, national academy of
medicine, and there’s so much about our broken health care system that we really can’t do anything about, that are in the hands of congress, insurance companies, big
pharma, the list goes on, but there was a business case to be made for doing something about
burnout, and this is something that we can do something about, and so I think for that reason, this has become a national issue. – I would add that all
of our national meetings, we see that leaders
recognize physician burnout as a serious issue. I think that it’s created
a framework for this now, and I think the major
shift that we’ve seen is a shift away from the expectation that physicians just sort
of build resiliency, and sort of strengthen their own ability to face some of the enormous challenges that are on the backs
of the clinical staff. The framework that I
find very, very useful is instead to focus on that sort of individual
responsibility piece, but make sure it’s really
heavily balanced against an institutionalized
responsibility to build a culture that’s supportive of wellness. And also, a commitment to improve the operational efficiencies
to support the practice. So, I think that’s a
really helpful framework to build from, so that we
can make some progress. – [Marschall] Thank you both. Let me direct the next question
to Srijan and Margaret. We know that many
individuals are struggling with a sense of burnout,
including our staff. What are the implications
for the care patients if we do not effectively address burnout? – So, yeah, really good question. As you mentioned, burnout, and depression, and the whole range of well-being measures are really strongly correlated
with medical errors. Burnt out physicians have twice the rate of medical errors as
non-burnt out physicians, but it certainly goes beyond that, and we know how stress
and sleep deprivation and not having enough
time narrows our thinking, and doesn’t allow to
consider as many diagnosis or to really spend time with patients, and to thrive and to be the
best physicans we can be, we really need to have
all of those things. Time, and sleep, and the
room to work with patients. So, certainly, there’s
metrics we already know that things will get better,
and costs will go down for hospitals and hospital
systems if we can reduce burnout and increase thriving, but I think that it will
help us in many ways we can’t even measure, yet. – I think as a family
doctor, I’m primed to think about longitude in relationships, and when I think about the destruction of a burned-out physician, on the relationships in a team, I think about the way that
then affects patient care. So, you can think that if
the leader of the team, or if someone who’s making
some of the decisions about the function of a team, is really stressed and perhaps fragile. You can think about the
cascade of interactions that that, then, impacts
thinking about the nurse, thinking about the call center, thinking about the way
that can cascade throughout a health system, or throughout
a patient experience in particular. I think it’s really important
to think about the data and how that drives us,
but I think it’s also to think about the human aspect
of physician, and a nurse, and a medical system, and
a pharmacist on a team, and if anyone or many of them
are stressed and fragile, it’s no surprise that that affects the way patients receive care. – [Marschall] Thank you. This question is for Kelly and Rob. Again, you’re both working on improving the faculty experience at your clinic. What are some of the important
things you’re focusing on, and what do you hope to achieve? – So, I’m doing this from
the general pediatric side, but it’s been really
interesting to work with rob and see where the similarities are in the general medicine issues, and where the differences
are, and then thinking about not only as we start these pilots. In our primary care roles,
how will these rule out other as a primary care, and then to some of the specialties,
and are the issues of burnout the same in those settings, or are they somewhat different? So, really, our focus
has been, I would say, building on what Rob already said, which is not assuming that
we just need all of us to be more focused on
participating in wellness programs, doing our yoga, doing
our mindful breathing, and then we will bring our best selves to the clinical encounters, and everybody will be happy. So, we’re really taking a really deep dive into what the systems approaches are that we’re currently using in our clinics, and how can those be improved from the ground up? So, one really deliberate
thing that we have done in our work with Chartis
is to be clear that this faculty experience process really is in the interest
of patient experience, and also staff experience. If we’re focusing just on the faculty, our staff is not gonna
be a lot more resilient or happy in their roles. Their roles may not be
more efficient and joyful and as such, our roles as
faculty are not going to improve. So, that being said, some
of the down and dirty work we’ve been doing is looking
at a lot of our processes, and we went through and entered a process at Briarwood Pediatrics
and West Ann Arbor Gen Med to look at where the things that are really clogging things
up, where are inefficiencies? Where is our wasted time occurring? What things are really bogged
down and not working well? So, really taking a quality
improvement approach, and then applying some lean strategies to try to improve things, and I’ll maybe let Rob talk about what the Gen Med ones are,
but for our pediatrics side, we’re working a lot on
the rooming process, which as you could
imagine, in primary care, can be a little bit chaotic when you might have three
children tagging along for the one baby that’s
there for their well visit. Our medical assistants
really have a tremendous amount of work that they need to do, so we’re really focusing in on what are appropriate
training and staff ratios. For our medical assistance,
many of our sites are currently and
chronically understaffed. As far as medical assistance,
I would say the role that they play in pediatric primary care is the most challenging
medical assistant role in the institution, and
so we have huge turnover if people see a role that they can move to a different clinic or a sub-specialty, the work will be about a tenth as much, and they may bring home the same paycheck. So, I think we need to
be critically looking at how we we train, retain, and reward our medical assistant staff, especially those in primary care. We’re looking at the rooming process, we’re looking at the
management In Basket messages, we are looking at all of the
forms we have to complete. So, we did a deep dive and
found that for every well visit in pediatrics, there
are three to six forms that parents need to fill out, and that means three to six forms that the medical assistant
has to enter on our behalf. So, you can imagine how much
that slows down our process. So, we’re looking at all
those areas of wasted time. We’re also looking at our efficiency and proficiency with Epic. We had a lot of training back in 2012 when we went live, and then
for the last five years, we’ve really done very
little to further enhance our proficiency, especially in using Epic. So, those are the main
areas that we’re looking at in general pediatrics. – First, I’d like to say I
really appreciate the fact that the institution is engaging
in an operational exercise to address the issues
of physician experience in parallel with a lot
of the ongoing efforts with the patient experience work. Having been involved in both of those, you can see how, in many
ways, it’s aligned, and yet if you just focus on some of
the individual initiatives that have our patients interests in mind. Issues of easy access and reduced
maximal use of every space in the schedule, and quick
turnaround of test results, and all of these things sound great, and we’re committed to making
sure that we give the patients the very best experience, but
if you just talk about those to the people on the front
line providing the care, it feels like do more. So, I think that the parallel
work that’s being done is something I really greatly appreciate, and I acknowledge that
the focus on primary care is really wonderful
for us in primary care, but I also understand
that this is a problem that affects people who are engaged in all different aspects of work, whether its hospital-based
work, or surgical work, or other cognitive specialties. So, I just wanted to make that clear. In general medicine, we’ve learned some
really important things. We are focusing on the
West Ann Arbor site, which is a new site, and
seems like a really good place to try and make some changes
as it’s getting up and running, and the goal is really to
identify some best practices that we hope to just share
across the enterprise, because that’s something that
I’ve really learned in my role supervising clinical faculty
at 10 different sites, is that local cultures develop, and then you bring in new
people to the local culture, and they learn the local culture, and there’s an opportunity for learnings across these various sites. So, in general medicine, what we have done is done some really great focus groups, so that the entire care
team representatives from the physicians, the
advanced practice professionals, the clerical staff, the
nursing staff, the MAs, and we’ve had really great dialogue about what the pressure points are, and from the faculty side,
we’ve heard loud and clear that the In Basket management
process is really a problem, and I thought I was gonna
be the first to mention the electronic health record. 10 minutes into this burnout session where we haven’t mentioned
the electronic health record, because it has fundamentally
changed the way that we’ve done our work, and some of the national literature on this is just fascinating to me, because they talk about the exam room becoming a cockpit, you know, and the physician is sitting
in front of a terminal, and what you see are the gauges and the dials of an advanced aircraft, and that’s how we’re practicing medicine on the frontline now. We certainly, I’ll echo
there’s important work that needs to be done to help optimize the efficiencies of all
of our individual users on the electronic health record, and there’s been some work done, and I see Jeff Terrill in the room, and my colleague Greta Brantford, who put together some
really user-based tutorials for how to not just do the
bare minimum to survive, but to actually thrive in
the system and optimize, so that actually kinda
rhymes a little bit. (soft chuckling) But at the ground level,
what we’re finding is that to get at this issue
of decompressing the In Basket, we’re really working on role clarity, and sort of what the expectations
are for various staff on how messages or telephone encounters, or in general medicine, we’ve learned that we have some forms, yes, but we have tons of test
results to sift through, and how to prioritize and make sure that things aren’t getting dropped. So, we’re gonna leverage what I think is one of the really important goals to try and address physician well-being is to enhance the
abilities of the care teams surrounding the physicians
as they’re doing their work. I don’t think this is a
unique thing to primary care, but certainly in primary care. It really is both necessary and rewarding to work within a group of
folks who are mutually engaged in the care of the patient. So, those are some of the issues. In Basket messaging, EHR
optimization, results management, and role clarity is what we’re working on. – Thank you, thank you both. One last question, then
we’ll open it to questions from all of you. This was to Kirk, who recently developed, and we conducted a
faculty survey on burnout. Can you give us a capsule of
what we learned from that, and how we might apply it? – Sure, I share a taskforce
on the, excuse me, (clearing throat) faculty and physician health initiative. And two other members of this panel are also on the taskforce,
and we developed a survey that was administered in November that 1,500 of us, including
many in this room, completed, and we now have some of
that data to share with you, and the first thing is that
more than 41% percent of us endorsed burnout symptoms
at a frequency and severity that would earn us extra
credit for burnout. (soft laughter) And this is despite 75%
percent of us scoring high on resiliency. So, this is not simply
a problem of resiliency. When we looked at these burnout
rates across departments, they ranged from 17% to 56%. So, there’s a wide range there, as well. When we looked at correlates, women endorsed the symptoms more than men. People in the ages of 46
to 55 had higher rates. People endorsing
self-designated minority status had higher rates. So, this is a DEI issue, as well. People who were on clinical track, and people who spent more
than 80% of their time delivering clinical care were more likely to endorse burnout. And people of professor
rank were least likely to report burnout. So, this was much more
in the earlier ranks. In terms of specific kind of stressors, only 1/3 of us said that
we had enough home time, and 50% of us said that
we spend either excessive or moderately high amounts of time doing EHR at home. 46% felt that their workload control, that their control over the
workload was poor or marginal, and 42% of us described
our workplace atmosphere as either hectic or chaotic. When we looked at the top five stressors, they were things like
email, clerical activity, time worked outside of regular hours, trying to meet all of our work
expectations and workload, time pressure. Now, our most commonly
employed coping strategy was finding meaning in work, but less than 50% of us used
all of our vacation time. On average, we slept less than the average recommended sleep
time of seven to eight hours. And almost all of us come
to work when we’re sick. Finally, 14% of us, in the past two weeks, met criteria for moderate
to severe depression, yet only 50% of us would seek help for a mental health concern, even if we had suicidal thoughts. So, I will leave it at that. I’m hoping that will raise some questions and also some solutions. Thank you. – [Marschall] Thank you all. As you can tell, we have
an extremely thoughtful and broad-based panel. Fortunate to have them here today. So, think this is a great opportunity to raise your questions. I’m not quite sure how the questions are. (soft murmuring) Okay, and so you’re checking
messages from offsite. Okay, so yeah. Questions? – [Girl] I was curious if
the survey included residents in the assessment? – Our survey did not include residents, but there was a resident
survey that also completed last year, so I’ll let. Srijan, do you want to speak to that? – Sure, I don’t know the exact numbers for the Michigan-specific house survey, but the rates along the
same lines in general about any given time
about 25% of the residents meet criteria for depression,
about 50% are burnt out, and the stigma issues might be even worse. Only about 15, 20% of the
residents who meet criteria for these problems get any help because of concerns about
what’ll happen to their careers and licensing issues
that Kirk talked about. – [Marschall] Yes, there
is a question back here. – [Girl] What are some of the next steps about what you’re gonna do
knowing this data at this point. What are some of the percentages
outside of gatherings to talk about their problems? – I can speak briefly about,
kind of at the microcosm of the family medicine residency program and some efforts that we’ve taken and then see if people
have other specifics. We’ve developed a framework
for thinking about wellness in residency, and, for me, I think it echoes what we heard from Dr. Orringer and Dr.
Ernst, which is that all of this starts with a
foundation of structural efforts that support wellness, and I think well this is, you know, I’m a
mom to three small children, and so a lot of my literature
reading is about parenting, and applying some of the
other theories that we bring to our work, I’ve been
applying some of the theories about parenting which are really wellness, stability,
wholeness comes from a place of simplicity, so as much as we can, simplifying the schedules and the work that our residents do, and
also providing more long-term relationships for them, so
we’re on the cusp of rolling out a new curriculum that
really hinges on concepts that allow for stability within a day, and allow more engagement
and depth of relationship on the teams in which they work, and my optimistic perspective
as a program director is that if we can help residents be whole, and graduate without… reaching the full depths of
burnout, that we can enhance the culture of wellness
for medicine long term, you know that this is really a point of impact, and that
I have a visual that I use when I describe this, which
is that it really hinges on a foundation of structural
changes that support wellness, and that uses
the literature that we know about leadership and
structures of wellness, but it also includes some
other pieces to the triangle, and one of those are the
specific tools that you hear people talk a lot about, and
that’s personal resilience, and mindfulness, and
some other strategies, but you’ll notice, those don’t work unless the structure is firm. Unless the structure is strong. And then the other piece
is some of what Kirk was getting at, which is this idea of professional identity
formation and engagement in the most meaningful work, and for me, that’s conversations
about what brought people to the culture of medicine,
what brought people to their practice, what
were the most meaningful encounters they had, and
also thinking about their own personal development as a trainee, and I think that resilience, mindfulness, professional identity
piece gets a lot stronger if we think about dedicated sick time. Our residents need to know there’s a culture where it’s safe. If you’re sick, you
shouldn’t come to work. They need to know we’re
gonna really engage in their continuity
practice, we’re gonna try to schedule them for full
days of clinics so they can attend to things over their
lunch hour with their nurse, so they could sit down
and actually eat lunch, so that they could join
the wellness committees at their clinical site,
and so for me, I want, I think to hear that echo
throughout for all of us is that the structure
really needs to be enhanced to support wellness. – I’d like to, if I
could, address a couple really specific, more
operational kind of next steps, because I’m sort of– couldn’t agree more at that
finding purpose in the work, Tom Schwank had something,
an opinion piece this past week saying “Only
by restoring their ability “to care will physicians
restore their health “and their professional soul.” And I think creating that
culture and the organizational climate where that can
happen is gonna require some specific things. So I qualify this, again,
understanding that this is different kinds of
physician work and my work is around primary care,
where there is some overlap on the board here, but my position as the Associate Division
Chief of General Medicine for Out-Patient Primary Care Faculty was created a few years ago, and it came out of some
really important institutional efforts around trying to better understand the issues related to primary care, and if I had a slide,
I would show one slide, which was presented by my
chairman, John Kruthers, who’s been a really
strong supportive leader in our department, I think,
for health and wellness of our faculty, and for primary
care, and he presented to the Institutional Clinical
Practice Committee in 2013 the findings of the
primary care task force which was charged by the
faculty group practice, and on his slide he had
eight things that he thought were drivers for the need to make change, and one was an observation
that morale was low. Number two, that the electronic
health record exposed and accentuated workflow issues. Number three, there were
significant issues related to access both for primary
care and to specialists, and those were stressing
not just our patients that we serve, but also
those of us that are trying to help patients navigate our system. Recruitment and retention
issues were really important, and being challenged,
and there was felt to be a salary differential between both. The health system and the
local market, as well as within the health system,
where we had in our own world, a bit of a dynamic between
primary care and hospitalists. That’s been addressed in many ways since many of these happened. It was bullet six, maybe? Many providers were
converting from full time to part time, and many
folks see that as a symptom of the problem nationally,
because if faculty members don’t have an opportunity
to engage academically or something else, and
don’t have any other levers to pull and control, they
feel the need to cut back, and then they, I don’t
think, work any less hard, they’re just doing it on their own time. Next is, there was an
unclear overall strategy for primary care and much
of this was unfortunately highlighted by the death
of a prominent primary care faculty member, and that
exposed and made public these issues of what
many of us were feeling. We were overwhelmed,
over-paneled, and the specific talking points about
what we could do were to, One: Address the issue of compensation. Number Two: Establish a
model for risk-adjusted panel capacity. What is the expectation? Because I think, as a
manager, as a middle-manager, what I’ve been doing is to try
and compensate people fairly, and give them clear expectations
of what success looks like, because I think most people
really really just want to do a good job. You could say that about
most people who work here. We have to address the issues
of physician work force, or workflow, rather,
looking at how the contact we have with patients
has changed dramatically in my 25 years as a
practicing general internist, where not only the opportunities
for patients to interact with us are more dynamic and different, but the expectation of
how quickly we respond is really really different, and
that’s pressuring people. That something simple, a
decision I would’ve made, but I really wouldn’t have
liked to make this decision, was to actually flip
the switch on My Chart, to allow patients to just
immediately see their test results same-day. When we went live with
My Chart, we all agreed, four days was enough
time to do two things, One: Get our heads together
and present the results with a plan, we thought
that was important. And number two: If you ordered a test on a Thursday or Friday, you at least had til
Monday to deal with it. Now we’re doing it same-day,
and it’s stressing people. We’re having to do our work differently. There are support resources that were felt to be necessary in the
clinics, and not just clear expectations for the care team, but innovative things like
voice recognition software and scribes, getting other
people in the office, and helping take on
different parts of the care. We really ought to think
deliberately about how we can enhance relationships
amongst ourselves. There’s a big deal with primary
care and sub-specialists, as the enterprise gets
wider and off the hill, there’s people who spend
no time on the hill, and if you didn’t train
here, you may not have those important
relationships that’s driven and informed important
work about the development of electronic consults to just get what many of us who have been
here forever took for granted, which was our back door curb-sides. Took me awhile to realize not
everybody had that currency or capitol, so we have to
build that for everyone. We applaud the institution
for coming up with better and more clear-defined
pathways for promotion on the clinical track. We’ve heard “The more clinical you are, “the more at-risk you are for burnout.” And I think in my world,
the clinical track faculty want to have some sense of recognition for their academic contributions. That leads to the next
one which is opportunity for teaching, because the
majority of my clinical track faculty identify as clinician educators, and we have to come up with creative ways to leverage that talent. And the last thing they
asked for was office space, so I dunno if that’s important. (chuckling)
That was the list of practical stuff that I
have used as a road map for things to work on to try
and address these issues. I don’t have anything else. Hocus pocus for the office
space, but all those other things I think are really practical
things that carry over to different specialties,
and that people can address from a practical standpoint
for what happens next. – I agree with everything Rob has said, and I will highlight
a few of those things. One is culture change, the
other is operational efficiency, which I think Rob addressed really well, and then of course there’s
our own self care activity. So, in terms of culture
change, I think that we can create a culture that
values our own health and well-being, and the
question is “How do we do that?” Well, for one thing, we
need a metric to measure it. We have survey results
that now provide us with the baseline that we
can continue to repeat and see how we’re doing on that metric. The other thing is that
once we have that metric, we can hold all of our leaders accountable for achieving that metric,
so maybe that’s gonna be Gee, we decrease burnout 5% or 10%, 5% a year, or 10% in two years, or something like that,
and we’ve got a measure to say whether or not we
are doing that or not. Anything that we can do
so that we as physicians operate at the top of our license will help decrease
burnout, and that’s where operational efficiency comes
in, and the pilot studies done in internal medicine and
pediatrics are so important. Rob said something else
that was really important, and it had to do with our relationships to each other, and this is so crucial, because when we are afraid of seeking help when wee need help because of stigma, because of lack of access, because of confidentiality issues, we have to appreciate
that the stigma is coming from our colleagues, or
we project it that we are the ones. When we’re not getting enough sleep, when we’re not taking our vacations, and when we’re coming to work sick, that’s because one, we
don’t want to disappoint our patients, but two, we
don’t want to disappoint each other. We don’t want to
disappoint our colleagues, and that’s a culture. That’s a culture, and that
culture is in our hands. We can do something about that. – [Marschall] Thank you. We’ve got another question, I want to make two quick comments, one is (clears throat) I’ve been going around
trying to speak to different departments, and last week on Saturday, I spoke to the urology department, and it’s a mish-mash, I
gave like fifteen minutes of different topics of
things that are going on, and I mentioned our efforts in burnout, and several of them spoke
up and said “What about us?” And actually urology, I
believe, was if not the highest, was one of the highest rated departments in terms of burnout, so
it is a broad problem. The other is I’m glad
to hear this dialogue and some of the things that
the panel has already said. I had the opportunity
to give a presentation at a different place, a
different university last week, and so I talked more about burnout, and what I could see is the
audience nodding their heads, and then looking kind of depressed, because I didn’t present
any solutions, I just said this is a big issue that
we need to be dealing with, and so I think you’re hearing
some thoughts about how we can address and we can’t do everything, but we really can prioritize what we do to try to improve this. With that editorial
comment, please proceed. – [Woman] So I just want to say thank you for having this, I’m actually
a medical student this year, and this is a passion
of mine, and it’s been kind of work on burnout,
depression and all sorts of things, and as a
medical student, I’ve been trying to do for about
a month essentially, and really creating that cultural change, and a few things that I think would be fantastic goals for the faculty is to have comfortable teams, is to
really be more transparent. I think if we see top physicians,
deans, and other people saying “Yeah, I struggled,
you know, I had depression. “I have anxiety, I constantly have it.” Or you know, anything where
there’s a lot of honesty, I think even just opening
the door will help with some of the stigma, and
I’ve found that first-hand, so last year, I went
through a major depression and anxiety, and I was
very open with my class, and I continue to be,
and I’ve already gotten to help people work through their stuff, and I’m not even a professional yet, so I think there’s a lot of
that (man clearing throat) and one of them needs
to be very transparent, and have our top leaders be transparent, and not expect that
transparency’s gonna come from someone who just started
their residency who is scared to be judged by their attending. So one of the things that
I would challenge you guys to find the solutions to is
ways to really work on this problem in a moment-to-moment way, so if someone comes in and
they’re sleep deprived, and they’re having kind of a crappy day, what do you do for them? Their day and their patient care is gonna go significantly
down, and I’m sure their whole team will notice it,
the patients will notice it, they’ll start to be more stressed out. It’s a bad cycle. So I want to challenge you to
come up with those solutions, essentially the equivalent
of a time-out and help out, and so really building
an, and even if it’s just a minute or two of acknowledgement, to say “Hey, I know you’re
feeling kind of crappy today, “if you need to just come
talk to me for 30 seconds, “I’ll listen.” And then you know, obviously
have a more of the over-arching quality thing. And the other is really the peer support, so I’m working on efforts to
hone in on a peer support, and official training
for our medical students, which I think would be
fantastic to have at all levels in this health system. – Thank you. Comments? – [Woman] They asked if they
could repeat the questions. – Oh, So briefly, yeah, the questions aren’t– – [Woman] They can’t hear them online. – They can’t hear them
online, so if you can… – [Woman] Along those– Along those same lines,
because I think I had a similar thought, and I love your ideas, is if you have a physician
who goes to a leader and says “I’m overwhelmed,
I feel like my workload “is overwhelming, I can’t get it done.” What would you encourage
your leaders to say and do for that physician and to that physician? – So two really good
questions, I think, one about physician leaders, and
leaders of institutions really talking about their own
problems more openly, and setting the culture that it’s
okay to have mental health problems and to talk about it. The other, what leaders should
do when people come to them with problems. Maybe I can try to address the first one. I think it’s great what
you’re doing, Claire, and other med students
here held a really nice piece and jam about her own depression, and I think that really
sets the stage for the next generation, talking
about this in a way that we haven’t yet, and I
think that’s important, just in my practice in
treating physicians, and physicians in training
often people who are struggling, who are going through
burnout and depression feel like they’re the only
ones going through it, that all of their colleagues
are not making mistakes, and getting all their
notes done and going home, and running five miles and
then making dinner and living the perfect live, but the
stats say that half of us, more than half of us are struggling, and the places where
we’ve seen that stigma broken through and people
talking about it openly, just that peer support like you mentioned, has a huge effect, and I think
the more and more we do that here at Michigan and nationally, we’ll make a real difference. Maybe I’ll pass on to
the others to talk about the second question. – These are really important questions. I think it was said
earlier, we built a really long-standing expectation
that we’re superheroes, right? We’re all the things that were just said. We’re supposed to be able to leap tall buildings and do all that stuff, and we’re not, right? And the culture is
there, and I think that, as much as we can,
address with transparency, when we see instances
of opportunity to share, that certainly helps. I also think that we need
to think operationally, because if we behave
like superheroes or try, the systems love that, you know? I think that as physicians,
we feel often times like we’ll just put the
patients on myself, because I can be the best MA in the building in any given moment, or let
me just call that patient back and explain it to them because I’m the best health educator
in the room right now, or I can do, I can do, I can do, and I think that the more
you do, there’s less of you. I did it twice, now! (audience laughing)
There’s poetry in action here! (fingers snapping) I do believe that
enhancing relationships is the secret to this, because
we care about relationships, we care about the relationships
with our patients, we care about the
relationships with the people we work with, and we care
about the relationships with the people who we
engage with outside our work, and we have to optimize
all of those relationships, and what we have control
over as leaders in our, whatever we have control
over, the areas those are, it’s important, I think,
to build out the teams and leverage the
capabilities of the teams, and even amongst
ourselves, working together allows us to create systems
that break down this notion that it’s gotta be me to do everything. So if you don’t have
some ability to cover, which I think is a huge gap
in our electronic health record thing, you know,
if I can keep up with the schedule and then
go back and check my lab results, and then figure
out all the messages, and then prep for the next day, that’s hard, what’s
even harder is when one of my colleagues is signed out to me, and I’ve got to do that same
thing with all of them, too. We don’t have great systems
for covering each other, and the best we can sort
of think creatively about creating some ability to cover each other, we’ll be able to do
with the second question is what do you tell
somebody who is struggling? And I’ve got this image
of my Chartis colleagues, you know, with this slide
that we’ve agreed isn’t the perfect slide, which
is this balancing thing between the, I’m gonna
paraphrase, the interests of each individual and the
interests of the system that are sometimes
weighing on one another, and I think as leaders,
that’s the image that I’ve got in my head. I do care deeply about
each of those individuals, but I’ve gotta keep an
eye on the operations of the system as a whole
also, so what can we build in advance to have some
capability to anticipate the need to be able to cover somebody, and to provide some individual support, just like we have to have
the ability to create a system in the clinic to
support each individual faculty, but we can’t just, you know, have waste, and to try and find the
right balance between that is the issue for leadership, I believe. That’s maybe overly too much. – These are really important questions, and I’m glad they’re being raised. I think that… when we are not doing
well, we do need to decide who we can talk to, and who we can’t, and if we decide that
our leader is someone that we can talk to, then we may want to we may want to go in there
with some of our own options and solutions figured
out to put on the table. I think that we expect
our leaders to listen. We expect our leaders to
see if some of these issues that are overwhelming have
to do with our culture, or with operational issues that are within the leaders’ control. We are presenting the
leader with an opportunity to pay attention to our
health and well-being, and therefor achieve the metric that they have, so I think that those are all things that we would
expect from our leader, and we expect kindness as well. I think we’re afraid to
do that because we get a message starting in medical school that you’re not allowed to be weak. You have to be strong, and or the superhero, as you put it. We learn patients first, and
we learn first “Do no harm.” And I think the fact that
we put patients first doesn’t mean that we’re second, right? Because we can’t put
our patients first if we don’t take care of ourselves. I think in addition to first “Do no harm”, we also need to be thinking
in terms of “Do no self-harm.” – I was thinking about, you
know, “What would I say?” and I was thinking this, as
a residency program director, comes up a lot. Somebody, you see them in the hall, you see a glimmer in their eye, you know this is a fragile moment, it can be a quick check-in,
“Is this, do you need “to talk right now, or should we check-in “after your clinic, or can
I call you after my kids “are in bed, tonight?” And I think it’s that
kind of awareness of: What is the need? What is the demand? And also an awareness of: Is there someone else you
can talk to about this? Is there someone else that
can help you with this? And I think that brief triage
can take thirty seconds to two minutes: Is this something we need
to intervene with right now? Is this something that’s
actually about the clinical flow? You told the front office
staff three weeks ago they could over-book you, and
now, for every clinic since then, you’ve been
over-booked by two patients, and that’s something that
is just super stressful, and I can look at the
schedules and level them out right now, and I can correct it. Or is this kind of a deeper dive? And I think for me, as a residency leader, it’s that awareness that
frequently it’s like a sixth sense, like, I need to, like tell me what’s happening,
just succinctly tell me, and I can triage: Is this something that I
need to address right now? Is this something that I can solve? Is this something that you
need to be pulled from clinic? I can think of times
when I’ve heard stories of residents at work
managing personal things that I can’t really fathom
why they didn’t call for help, someone having a miscarriage on-call… People really work through
things that emotionally or physically, you
wouldn’t expect them to, and so I think it behooves
everyone in the culture to be mindful that, behind the physician, the nurse, the medical student, the MA, we’re all people first. I think that looking at it like that can be really helpful. Speaking to the peer element, actually, Heather Burroughs is
here, and Heather and I frequently go for walks and talks, and we manage some of
the things that happen as program directors by talking through issues together, but we’ve
combined it with a walk. We get out and get fresh air, we kind of, I don’t want to say that
every time I exercise, it’s also combined with
work or with peer support, or friendship, but that there can be some mutual benefit from the
ways in which we work, and then also, because
Philip Zazove is here, my Chair, I think there’s
a lot to be said for a culture where… Philip really fosters a
culture of thinking through what matters most to the
people that are caring for patients and for
me, making changes in my professional life, he
said “It’s important that “we innovate. “How do you want to see patients? “Do you want to do a
little bit more procedures, “and see only 10 patients instead of 14? “Let’s try it and check
in in three months.” I think a willingness to try new things with faculty to allow them
to meet the business needs, and the patient care needs, but also their personal needs is a really valuable thing to look for in leadership
and in the institution. – I just have one really practical thing, so we are 90% women in
our 60 faculty groups, so many maternity leaves. We had 11 maternity
leaves to cover last year, and three long-term, six months or longer, medical leaves, so you
can imagine how that would decimate the nine clinic sites we have. We have a minimum of four FTE at all times at float positions who
help cover the lead, so I think there’s some
kind of practical things that we can share across our
groups that also kinda help, because yes, I’m very
sensitive to those folks who are struggling, but
as a leader, I also have to make sure that there continues to be patient access at our
sites, and that I don’t create burnout in the three
faculty that are left there holding the bag because one
person’s off on a medical leave, so I think that’s a really nice way, and we’ve found it actually
financially very feasible to do that. – I just wanted to build
just a little bit on that and say that intuitively,
there’s often a sense that to what you’re saying, that
the system and being kind to these individuals are opposed, but the data is actually
showing that it’s better for the system if we have
floating positions that can take care of coverage and
then people are more willing to take their vacations
and take adequate leave, and stay home when they’re sick, and are more productive,
and systems make more money when we have things like that and scribes, and so really these things aren’t opposed, and the more we do this,
the better it’ll be for patients and the finances
of health care systems. – [Marschall] Thank you all. You must’ve been reading
this type over my shoulder, I can’t even read it right in front of me, but this is a question from
outside that really follows along with what you all
were just talking about. It says “I’m concerned
about the other Chartis “initiative to improve
access being at odds “with maintaining our
ability to practice medicine “as we best see fit, and
the ability to maintain “that important reciprocal
energizing relationship “between physician and
patient that makes this “hard job worthwhile and rewarding.” Can you speak to that? – Rob and I have been really
involved in this work. I think when you hear
sort of the one-liner, you think “Oh my goodness,
it’s gonna be us doing more”, but really the essence
of this work again is, giving the right care to the right patient at the right time. So it’s not just delivering more care that maybe isn’t needed,
isn’t appropriate that time. Is delivered in an
office one-on-one visits, so we’re looking at
tele-health opportunities, ways to maximize our
communications to families across the portal, ways to
use our nurse educators, social workers, registered
dieticians, psychologists, so it again this idea of this care team, everyone working to the
top of their license caring for a panel of
patients and giving everybody the care they need, not
delivering everybody the same amount of care and
that equaling more care, so I would say I’m
actually really energized by the work we’re doing,
because I feel like we can really target what families
and children within those families need. Working a lot more on the
social determinants of health, which I think is
definitely for pediatrics, that is essential, and
hopefully decreasing and helping educate families
on why they don’t need to come in and see us for
a one-on-one office visit for every little thing that happens with their child and empowering
educating families and parents how to manage
most of those common illnesses which used to be the core
of general pediatrics, and we now really can educate parents that we don’t need to see their kids for a lot of that stuff,
we’re gonna focus on the anticipatory guidance,
moving them through on a really strong developmental
and wellness trajectory. So I think it can really
transform our practice. – And just to jump in there and talk about the way in which we’re paid
and that’s a way in which we’re valued which is to think about that as asynchronous
care, and for physicians, sometimes from the
patient perspective, it’s “Oh my gosh, my doctor got back to me! “They’re so quick! “That’s so great!” But that’s un-billed
time, that’s really time, that is this time that’s
the work after work, and I think institutionally, that asynchronous care needs
to be valued for what it is. It’s a cognitive emotional
thoughtful work of being a high-quality physician. – I want to just address
the question about the Chartis access work as
being a concern about being received by many as saying “I just need to work harder.” I led with that because I think if that’s the only initiative
we were working on, it would be a perfectly
understandable concern for many people who are engaged mostly in providing the service. It’s what I think is so important, that the institution is
balancing and working on both physician experience as well as the patient experience together. I will tell you, I have
been very much involved in both of those processes. I find it actually really
helpful to bring in somebody, a team of
folks, I’m talking about my colleagues, my Chartis
colleagues up here, to just add information
about our practice. We experience the
practice, and I think that someone who’s analyzing
the practice and then experiencing the practice
get mutual learnings when those get into the room,
and we’ve learned some things. I will also say that
the going in position of just saying “Let’s just
increase your panel, “fill all your slots, and
wind you up more clinics.” And things like that. You know, those things
aren’t the outcomes, and I think every single meeting we had, there was movement on
some of the learnings that came. I will tell you, I think
that access to our patients is really important, and if anybody lives in Ann Arbor and has
friends who are trying to get appointments, you hear about that. I hear about it all the time. And I know as a practicing physician, getting my patients to see my colleagues and whatever specialty is a huge problem, and I think that if
organization can look at our operations and find opportunities to improve that, that helps the patients, and it helps us, and we
can build efficiencies. The final slide when
we were doing our work on the access piece, I really appreciated because it came up with some
suggested schedule templates to add efficiencies, and
to create space for adding new patients on access, but there was some ideas to say listen, we’re deploying nurse practitioners and PAs to the clinics without a sort of uniform
sort of understanding of how that is helping or, and we need to think about
that and come up with an institutional approach to that. And then the last was I
don’t think we can do this unless we ensure that
we have effective clinic support resources and care
teams configured in a way that will allow us to
have folks work at their what we consider to be
capacity or near-capacity. So I really appreciated some of those findings that didn’t just
say “We’ll just, you know, “wind people up a little bit more.” – [Marschall] Thank you very much. Our time’s near ending,
so I wanted to make just a few closing remarks. First is, I wanted to thank our panel. Really, you had a chance to talk to people who’ve thought about this, who are real experts
and very caring in terms of how we think about moving
forward with this problem that effects most of us if not all of us. I think that there’s obviously no
switch to flip that turns it on and turns it off,
and the key will be working in my view, working
through how we prioritize really changes, I’ll
call them operational, they’re not just operational,
but operational changes in how we do our jobs and
how we live our lives, and again there won’t be a single formula for anybody, but I really encourage you, as you think about this,
to provide feedback, because this is early in
our evolution in trying to take this journey. I will just make this comment which is, I really got my first deep
exposure to this last summer, and was really impressed
with some of the folks that were in a discussion that I attended, and I think it’s unknown whether if you staff clinics in the way that
we anticipate staffing them what the financial impact will be, but I’ll tell you what,
I think there’s at least as good a chance that it’ll
improve our financial status as it will hurt our financial status. We may not get it right the first time, but I’m committed to us doing this. The reason we started this
pilot because we can’t do it in I don’t know
how many clinics we have, but lots of clinics, but
I think we’ll learn a lot from these pilots, and
then we’ll think about how to take the next step. I’m of the belief that we’ll
learn quickly from this, we’ll learn in some months. I guess I would just close
by thanking all of you, I know that as we’ve just
talked about, time is precious, and you took some of your
time, and you took an hour to be here today, and
that’s an hour that comes out of somewhere else, and
so I do appreciate that, I appreciate your thinking about it, and I look forward to,
and I know all of us look forward to your feedback and thoughts about how we can uniquely
address this problem. We’re committed to doing it. You’ve just heard that from this group, and you’ll hear it from many others. So let’s figure out a
way that we can improve all of our lives, and improve
those of our patients. Thank you. (crowd applauding)

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